This book encompasses both a ‘comprehensive’ overview of the CRM model for the treatment of trauma developed by Lisa Schwarz and an exploration, largely based on the work of Dr Frank Corrigan, of the neuroscientific basis of its efficacy. This twin focus makes for a somewhat hybrid reading experience, as we move between neurobiological and clinical themes and implicitly different theories of the Self.

However, both trajectories are rooted in what seems to me to be a highly significant development in our understanding of trauma and of the importance of working with it relationally. For the book adds neurobiological heft to the growing evidence that what is now being recognised as Complex PTSD (as a diagnostic category distinct from PTSD) often has roots in early attachment trauma.

To oversimplify radically, the premise of the book goes something like this: the early trauma of attachment disruption is, by definition, faced alone. It therefore needs to be repaired within and by an experience of relationship, be that interpersonally – other-to-self (therapist to client) or intra-personally – self-to-self (a benign, imagined Other which supports a young part to step into its dreaded traumatic isolation and re- experience it from a resourced position, leading to memory reconsolidation and repair) – though, of course, it is not either one or the other but both. To coin a phrase, the therapeutic relationship is seen here as necessary but not sufficient. In this regard, and for all that there is a chapter devoted to it, it could be argued that CRM underestimates the contribution to healing of the attuned relationship, which is sometimes described as if it were simply a platform of somatic attunement from which protocols can be delivered, rather than itself a source of reliability, regulation, mirroring and developmental repair. But this is no doubt because the emphasis of the book is on breaking new ground – on hypothesizing the role of mid-brain neurobiology in the experience of traumatic attachment disruption and arguing that only protocols designed to work specifically with these brain systems can be effective in its resolution. Whether what might be described as ‘neuro-therapy’ is the main objective of a healing relationship is open to question. But what is germane for consideration by relational psychotherapies is that these resourcing protocols are themselves fundamentally relational. This is perhaps why I found it possible to integrate CRM organically within a CAT framework rather than its being a useful additional tool for the middle phase.

A CAT practitioner for 8 years, I trained in CRM extensively over several years after surfing what felt like of a wave of developments in the treatment of trauma and in the neuroscience underpinning them. From Sensorimotor Psychotherapy, via EMDR and Brainspotting, I had found myself garnering a whole array of tools for trauma work for use in the middle phase of my CAT work. I found (and continue to find) that each has something to offer, but that none were the ‘magic bullet’ that each maybe claimed to be and none felt particularly coherent with a relational model. In my view, this is because they do not address the fundamental issue of trauma in early attachment, or more broadly in formative relational experience, as the driver for what CAT might call dysfunctional but aim-directed relational procedures. CRM may not have or be the last word either, but this, its fundamental tenet, is at the heart of why addressing the material offered in this book is an important generic task.

From the outset I found there were natural affinities between CRM and CAT, both clinically and theoretically, especially given their emphasis on relationship, and that interplay between them could be mutually enhancing. This book might not be the most apt instrument for making that case, however, for the same reasons that my perspective might not always be welcomed within CRM. Like any new movement, it can seem more keen to emphasise its uniqueness than to acknowledge links and affinities with other models and in the book this comes over as what Harold Bloom once described as an ‘anxiety of influence’.

On the one hand, one writer (LS) acknowledges that the model is a synthesis of lots of experiences of and in therapy and healing and scrupulously acknowledges personal sources; on the other, there appears to be some difficulty with recognizing the broader matrix of clinical cultures within which this work swims – indeed, Colin Ross’s trauma model is asserted as the only influence on the work. Having embraced the former, the latter does not make sense to me: I welcomed CRM as a magpie model bringing together – in a new synthesis and with enhanced neurobiological foundations – many tools from my existing kitbag. It felt like a kind of home-coming. From Gendlin’s Focusing (particularly when used to track and attune to somatic experience) to Leuner’s Guided Affective Imagery, with its roots in psychoanalysis and its affinities with some shamanic practices; from parts/ego-state/self-state work to ‘working with the frozen child within’; from the use of clean language to induce Ericksonian trance-like states to the involvement of the visual cortex in EMDR, the genius of CRM seemed to lie in its capacity to draw all these tools together in a way that gave them a more focused purpose and direction, viz. to serve the fundamental premises of CRM. These are as follows:

• that trauma in early attachment is at the heart of what the ICD 11 is about to distinguish as Complex PTSD and that it is also increasingly clear that this is likely to be the underlying cause of what are now classed as Personality Disorders as well as DID, DDNOS and DESNOS and other mental health diagnoses;

• that such trauma is stored in areas of the mid-brain which are not available to top-down reprocessing by cognitive approaches. This challenges the emphasis currently placed on CBT- based treatments for trauma. There is also a challenge to exposure therapy, this being an essentially behavioural approach to what is now being understood in terms of brain chemistry shaped by and rooted in attachment trauma. The new hypothesis suggests that even consciously embodied approaches like Sensorimotor Psychotherapy do not reach the appropriate level of brain function, since the basal ganglia involved in sensorimotor responses are positioned above the mid-brain, including the periaqueductal grey (hereafter the PAG), where the hard-wired neural networks implicated in human survival responses are laid down.

These arguments are put forward very effectively in the chapters on neuroscience. While clearly addressing a learned neuroscientific magisterium, these are also written with an eye to a relatively lay reader. They set out their hypotheses and describe the neurological processes involved with welcome clarity for the most part. Occasionally the detail is overwhelming rather than illuminating as when, for example, the description of the brain activity underlying ‘Core Self ’ turns into a complex list of areas of the brain that may be involved which does little to strengthen the argument for this concept and begs existential questions about it. But elsewhere the detail is invaluable and clearly clinically tested: from the further development of Corrigan’s award- winning work on dissociation to the detailed analysis of the neurological basis for using specific breathing exercises, the work is persuasive and immediately useful. As I hope will be clear throughout this review, the neurobiological case for CRM is a significant contribution to the current debate on approaches to attachment trauma.

What is missing perhaps is a recognition of this wider debate and of other perspectives within it.

Neurobiological sources are amply referenced (especially Panksepp, his research on hard-wired emotional systems being key to CRM theory), but the work of other major thinkers on attachment – Porges, van der Kolk, Stern, Damasio, to name but a few – is not discussed. The omission of Porges seems particularly significant: his polyvagal theory of social engagement maps similar areas of the brain and gives a socio- biological perspective on attachment and bonding. Furthermore, his explanation of vocalization would have underpinned the use of toning in CRM, to help new learning to become embodied. The intention is clearly to focus on the case being made for the importance of the mid- brain, but it seems to me that the effect is to denude the attachment element of CRM of context, thereby impoverishing it somewhat.

But perhaps that is to ask that this be a different book. The focus and task of the one before us is the necessary one of making the case for CRM and making its methods known. Other chapters almost exhaustively outline all the treatment protocols which make up the core model. While the reader is warned ‘not to try this at home’ without proper training, the address nonetheless resembles that of a training manual, the purpose of which is to explain the ‘why and how’ of every permutation on the resourcing protocols, with menus, caveats, counter-indications and trouble- shooting given for each. This will, no doubt, be very useful, by way of consolidation and as an ongoing point of reference, to people who have done the training – and indeed the book has been welcomed with excellent reviews by members of the CRM family. But for the new reader I fear the wealth of sometimes contradictory detail, the unexplained language (Magic Question? Energy exit?) and the failure to address questions about the provenance of some of the tools (to discuss the terminology of Safe/Sacred Place without reference to its use in EMDR seemed especially odd) might be off-putting in different ways.

And the teaching style is relentlessly homogeneous. There are no diagrams (clarifying the scaffolding and building blocks of the model, delineating the parts of the brain and their functions, outlining the processes of attachment disruption) and no actual case studies to illustrate and vary the pedagogical tone. More effective editing might have helped the writers see their material from the point of view of a beginner’s mind and make it more digestible.

But it is important not to allow imperfections in the text to diminish the dance of clinical intertextuality that can emerge from a dialogue between CRM and CAT. Both emphasize the centrality of formative early relationship experiences – Reciprocal Roles in CAT – and the different valences of the sense of self (‘self-states’ in CAT, ‘parts’ in CRM) that are born out of these experiences. For similar reasons, both emphasize the importance of the therapeutic relationship and both work with the intrapsychic self-to-self relationship of the client. In CRM though, there is little or no emphasis on the current self-to-other sequelae of RR experiences, the premise being, I think, that people who have experienced a level of early attachment disruption that impairs their capacity to experience affiliation, will be healed when once the ‘dandelion root’ of this pivotal experience has been reprocessed and reconsolidated, with ensuing alterations in brain chemistry, and in the hormonal valency of the PAG in particular. This perfuses other areas of the brain leading to changes in experience, behaviour, interaction and the ‘field’ around the person.

I have witnessed shifts like this occurring in my own clinical work with CRM. Nonetheless, the lack of an explicit lens for exploring current procedures manifesting in self-to-other RRs is a weakness of the CRM model in my view. In particular, I notice that I often rely on CAT to build a collaborative hypothesis with a client, especially where the sequelae of early attachment disruption are such that the establishment of trust between therapist and client is the prima facie challenge in the work. Here the client’s relational ‘procedures’ need to be identified, accepted and mutually agreed before any kind of ‘treatment’ can be consented. There is no substitute for the brave, risky work of gauging the ZPD and skilfully finding a way to name what is happening in the room. In these circumstances, a CRM therapist might advise jumping straight in and teaching breathing, offering a somatic or attachment resource, to begin healing the sequelae and their source as they present in the room. And sometimes this might be necessary as ‘first aid’. But, for the most part, where I have begun CRM work without a reformulation and a map, without this documentation of an agreed understanding, I have found that the work can start to feel very complicated and rudderless, as we excavate different layers of experience and go from one CRM resource to another. Experience has taught me that shared documented reformulation is a better basis for the work than a therapist’s inductive hypothesis, even when this is agreed verbally with the client. While this cognitive element to the work – especially one which documents insights achieved in and about relationship procedures – may not reach the mid-brain/PAG, it seems to anchor the vessel of the therapy while the working couple dive from it into the underwater world. It also maintains a focus on the here and now matrix of the client’s other important relationships.

To stay with mapping for a moment, it is also the case, conversely, that CRM can enhance the focus and significance of what is mapped and the depth at which it is possible to work within a CAT framework. I am often mindful of and use Steve Potter’s tripartite division of the map into:

1. the central area of procedural traps, self-state switches, snags and dilemmas which is ‘chronically endured’ but keep us safely out of

2. the lower depths of feeling that are ‘desperately avoided’ (what CRM, after Colin Ross, would call ‘the truth of the life’, the limbic experience of survival terror – perhaps, what CAT used to call the Core Pain) as well as preventing us from ever attaining

3. what is most ‘desired’.

This description is mirrored almost exactly in the opening paragraph of the CRM book which articulates thus the profound ‘trap’ that is the legacy of early attachment trauma:

‘The harsh reality is that the experience of a chronic, visceral state of fear blocks the capacity for love, which is the very thing needed to heal. . . What can be done to resolve the dilemma that only love conquers fear but fear prevents access to love?’ (p.2)

CRM offers a series of protocols which can enable a client to ‘access all areas’ they have been precisely ‘desperately avoiding’. By providing sufficient resourcing in neural loops running parallel to those storing traumatic material in the mid-brain, they enable the client to bring attention to, step into and articulate painful affective and somatic experiences and in doing so facilitate re-processing and repair. And there is emerging evidence of the efficacy of the precise and brain-relevant protocols of CRM in research by Ruth Lanius, recording fMR Imaging of brains before and after CRM sessions. To what extent other factors are at work in these neurological changes, and what these shifts in turn might facilitate, only carefully designed further research could determine.

While it is my experience that the model can indeed enable profound shifts, to claim that clients get ‘cleared’ in some final way also seems to me to over-egg the cookie. ‘Neuro-therapy’ alone cannot address the complexity of the human condition. As Porges, writing on social engagement theory, points out, we are all constantly exposed to difficult and shaming experiences in the hurly-burly of socialized living among other human animals. Rather than trumpeting an idealised ‘ever-after’ in which difficulties are excised, it feels more realistic to hope – with CAT and with Porges – for ever more profound ‘exits’. A resource- full therapy, building new synaptic pathways, might bring what was hitherto ‘desperately avoided’ into the mindful purview of the Observing Eye, giving new perspective on familiar emotional responses, building resilience and enabling different choices. People might still face difficult here-and-now challenges about problematic relationships, illness, aging; but the resolution of early attachment trauma might release them from the life-limiting trauma responses of submission, fight, flight or fear-driven attachments to bad objects and enable them to access other hard-wired neural networks, such as curiosity, playfulness and the positive seeking of affiliation.

This book might have its imperfections, its focus sometimes seeming laboured and narrow, but it is important to remember that pioneers who break new ground necessarily have a specific focus. It is perhaps for those who come after to see how what is discovered fits into a wider context. Indeed, in their conclusion, and in a change of tone, the authors acknowledge this and issue an invitation to their readers to develop the work further. I would urge practitioners of relational therapies (including CAT) to accept that invitation, integrating insights from this model of attachment trauma work into both their theory and practice. Experienced clinicians will already have many of the skills and tools that CRM synthesizes and orchestrates in the service of resourcing, reprocessing and reconsolidation. And I hope I have illustrated here how the tools we use in an approach such as CAT already lend themselves to deepening our sensitivity to the out-workings of this kind of early trauma: perhaps they could be fine-tuned further in this direction.

In short, this book is a valuable contribution to the debate around the treatment of trauma and the recognition of its importance, and a strong argument for the importance of its taking place within a relational psychotherapeutic model.

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Acknowledgement:

I would like to acknowledge the contribution to my thinking and my clinical work of my supervision group at the Cullen Centre – Julie Donegan, Dr Dee Affleck and Dr Kathryn Watt – and that of Dr Frank Corrigan whose collegial input and collaboration has been invaluable.

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Catherine Shea 

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Cite as: Shea, C. (2018). The Comprehensive Resource Model: Effective Therapeutic Techniques for the Healing of Complex Trauma [Review of The Comprehensive Resource Model: Effective Therapeutic Techniques for the Healing of Complex Trauma, by L. Schwartz, F. Corrigan, A. Hull, & R. Raju ]. International Journal of Cognitive Analytic Therapy and Relational Mental Health, 2(1), 147–153. https://www.internationalcat.org/_files/ugd/ff32b4_21750314c8f046029514e413ec563e21.pdf