Received: 16 September 2020
| Accepted: 29 April 2021
DOI: 10.1111/1467-6427.12353
ORIGINAL ARTICLE
Systemic and family therapy with socially
disadvantaged children and young people with
complex trauma
Steve Cobbett
Beckmead Family of Schools, London,
United Kingdom of Great Britain and
Northern Ireland
Correspondence
Steve Cobbett, Beckmead Family of
Schools, Monks Orchard Road, Bromley,
BR3 3BZ, United Kingdom of Great
Britain and Northern Ireland.
Email: stevecobbett456@gmail.com
© 2021 The Association for Family Therapy and Systemic Practice
J Fam Ther. 2022;44:205–223.  wileyonlinelibrary.com/journal/joft
Abstract
Young people who have experienced complex trauma are
often under-­reached by statutory therapeutic provisions.
Systemic therapy has potential for these clients as many of
their difficulties are systemic in nature but adaptations to
practice can be beneficial in order to support engagement
and enhance positive outcomes. I describe an approach
based on several years of practice experience which in-
cludes using expressive and physical activities, attending
to issues of power and difference, using non-­clinical set-
tings, providing long term attachment-­informed therapy,
combining family with individual work and adopting an
integrative practice that combines systemic and other ap-
proaches. The paper illustrates this approach with refer-
ence to theoretical explanations, practice experience and
case material.
KEYWORDS
attachment, children, complex trauma, integrative, males, social
disadvantage, systemic and family therapy, working-­class, young
people
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Practitioner points
• Systemic and family therapy with adaptations can be an effective intervention for socially disad-
vantaged young people with histories of complex trauma and their families
• Because of the complexity of both need and symptomology it may be helpful to synthesise ele-
ments of evidence-­based practices (EBPs) which target particular symptomologies and also to use
strategies that address the engagement difficulties often encountered with EBPs.
• Particular strategies that can aid engagement and therapeutic process include making available the
option of non-­verbal activities, providing therapy in school and at home, attending to attachment
needs (including availability of long-­term work and individual sessions for young people) and
tailoring therapy to suit the particular needs of male, minority ethnic and working-­class clients.

I NT RO D U C TIO N

Since 2004, I have worked as a school-­based therapist with young people described in the UK educa-
tional context as having social, emotional and mental health needs (SEMH) (Department for Education,
2014) and their families. Children1 with SEMH are a significant and growing population, with gov-
ernment figures recording 233,300 for 2019/2020 in England alone (DoE, 2020a). Most young people
identified as having SEMH are boys (72% in 2019/2020; DoE, 2020b) and display externalising be-
haviours such as aggression (Cooper, 2010) which tend to create more of a problem in the classroom
than internalising behaviours such as withdrawal and thus are more likely to be identified in the con-
text of the education system. These two factors are probably linked in that boys and girls often display
their emotions differently, particularly in response to trauma (Dulmus et al., 2004). This may be be-
cause of the different ways that children are socialised to express emotions based on gender expecta-
tions (Rosenfield, 2000), although there may also be a biological element (Martel, 2013; Susman
et al., 1987). There is a clear link between SEMH and social disadvantage (Brown et al., 2012), with
40% of pupils identified with SEMH eligible for free school meals as opposed to the national average
of 16% (Holt et al., 2019). In my practice, the vast majority of my clients have experienced both long-­
term trauma such as domestic abuse and insecure attachment to caregivers, a combination that is in-
creasingly being referred to as complex trauma (CT). Such young people are a population at
considerable risk in many ways, and if they do not receive the necessary support (including therapy),
their life outcomes are poor and many will go on to parent similar children, thus repeating the cycle
(Cooper, 2010; Fergusson & Horwood, 1998). Such young people often struggle to engage with ther-
apeutic support and are under-­reached by mental health services (Davidson, 2008; Wierzbicki &
Pekarik, 1993). There is a need then to innovate in terms of providing young people with SEMH and
their families with accessible therapeutic support, and this has informed the development of my prac-
tice. Social deprivation and oppression, trauma, insecure attachment, ethnic diversity and the male
gender all feature heavily in my work, and each of those aspects has influenced the integrative sys-
temic approach that I will describe in this article.

1
Throughout this article, I will alternate the use of child or young person to refer to those of UK school age (i.e., 5–­18 years
old).
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SYSTEMIC THERAPY WITH CHILDREN AND YOUNG PEOPLE WITH
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Complex trauma

CT is an emerging concept that describes significant long-­term interpersonal trauma which may be
chronic or episodic. When this occurs in childhood, it may also be referred to as developmental trauma
and is usually accompanied by disruption to secure attachment to caregivers, with resulting attach-
ment difficulties a significant feature. It affects a significant population of young people (Kliethermes
et al., 2014), and this may be partly linked to the significant levels of neglect and abuse in our society,
with 16% of 18–­24-­year -­olds in the UK reporting experience of severe maltreatment (May-­Chahal &
Cawson, 2005). CT may emerge in situations where primary caregivers are themselves perpetrators
of abuse or in situations where caregivers’ ability to provide secure attachment is compromised by
a shared trauma (e.g., domestic violence). Its long-­term effects are pervasive and multi-­faceted and
have been categorised in the form of seven domains which are self-­concept, attachment, biology, af-
fect regulation, dissociation, behavioural control and cognition (Cook et al., 2005). Symptomology
is therefore correspondingly complex and does not fall neatly into existing trauma-­related diagnoses
such as post-­traumatic stress disorder (PTSD), conduct disorder or borderline personality disorder.
There is also a clear systemic context to CT in that it is more likely to occur in socially deprived com-
munities and is exacerbated by experiences of prejudice and oppression (Briere & Lanktree, 2008;
Chia-­Chen Chen et al., 2007).
Some authors and researchers position CT within the medical narrative (e.g., Van der Kolk, 2017),
and this has led to proposals for new psychiatric diagnoses such as complex post-­traumatic stress
disorder (CPTSD) and developmental trauma disorder (CPTSD has been included in ICD-­11, but
neither has been included in DSM-­5). Others emphasise the systemic aspects and the need to work
with those aspects (Collins et al., 2011; Rawles, 2010). As a systemic therapist, I question the med-
icalisation of trauma generally, and I agree with Lannaman and McNamee (2020), who suggest that
this approach fails to acknowledge the significance of social aspects and pathologises individuals. I
do, however, recognise the reality of the biological effects of trauma in individuals, such as an over-
active fight–­f light system and agree with Cozolino (2010), who believes that an understanding of the
neuro-­physiological aspects of trauma can be helpful both to therapists and clients. I favour a both/
and lens on CT in that biological and systemic aspects are both significant and interweave in multi-­
layered ways.

Evidence-­based practices for complex trauma

As neither CT nor developmental trauma are yet widely recognised as diagnoses, there are essen-
tially no established evidence-­based practices (EBPs). However, in my practice experience, young
people with CT tend to be offered treatments from statutory services that are either tailored to PTSD
symptoms or conduct disorder symptoms, even though they generally have complex symptoms that
span both diagnoses. It is therefore relevant to examine these EBPs. Three well-­supported mod-
els are trauma-­focused cognitive behavioural therapy (TF-­CBT), functional family therapy (FFT)
and multisystemic therapy (MST). TF-­CBT is primarily used with young people with PTSD symp-
toms, whereas FFT and MST are used for anti-­social behaviour and conduct difficulties. Eye move-
ment desensitisation and reprocessing (EMDR) also shows promise for treating PTSD symptoms,
although the evidence for children and young people is not as convincing as for TF-­CBT, largely
because of small sample sizes and methodological inconsistencies (Leenarts et al., 2013; Schneider
et al., 2013).
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TF-­CBT primarily involves individual child sessions plus some separate parent2 sessions and one
or two conjoint family sessions at the end. It helps children develop coping strategies, understand their
symptoms through psychoeducation and process their trauma through forming a narrative, and helps
parents to support their children's recovery. It has a generally favourable evidence base for PTSD
symptoms (Cary & McMillan, 2012; Cohen et al., 2006), although the evidence appears mixed for CT.
The developers of TF-­CBT describe adaptations to the treatment process for CT (Cohen et al., 2012)
and cite evidence of positive outcomes from three pieces of research. However, one of these only
showed improvements for PTSD symptoms and is not published (Cohen & Mannarino, 2011), and
another is a personal communication to the authors and related to the specific traumas of sex traffick-
ing and being a child soldier. Participants in the third study had experience of ‘discreet traumatic
events’, and there was no true control group as the comparison treatments were for different age
groups (Weiner et al., 2009). In addition, dropout rates for TF-­CBT are a concern (Wamser-­Nanney &
Steinzor, 2017; Yasinski et al., 2018), with rates between 33% and 77% being reported.
FFT and MST are both systemic models that promote change in family relationships to help reduce
the young person's problematic behaviours. Both models also work to support the family's relationship
with other systems such as schools and other community resources. There is good evidence for FFT and
MST generally for conduct difficulties (Curtis et al., 2004; Hartnett et al., 2017; Henggeler & Sheidow,
2003; Van der Stouwe et al., 2014). However, a meta-­analysis showed that MST was less effective with
minority ethnic young people and young people outside of the United States (Van der Stouwe et al., 2014),
indicating possible cultural barriers. MST was also found to be less likely to be effective with young peo-
ple involved in gangs (Boxer, 2011), which is common amongst CT-­affected youth. Littell (2005, 2006)
questions the quality of the evidence for MST in a number of respects and notes that much of it has been
generated by the developers. Weisman and Montgomery (2020), in their meta-­analysis of FFT, found that
half of the studies were authored by FFT developers, and there was a marked difference between the re-
sults of their studies (all found positive effects) and the independent studies (all but one found null effects).
Other authors report difficulties for FFT with engagement. For example, Watkins et al. (2020) found that
only 28% completed in a study of court-­involved youth in the United States. A UK study (Humayun et al.,
2017) cited a 40% dropout rate amongst offending and anti-­social youth. Other researchers cite a lack of
evidence with working class, non-­White and high-­risk young people (Darnell & Schular, 2015; Weisman
& Montgomery, 2020). A report by the Early Intervention Foundation (2019) summarised mixed results
for FFT and highlighted a lack of long-­term evidence and incorporation of dropout data into the evidence.
Littell (2005) similarly highlighted lack of incorporation of dropouts in the MST evidence.

Rationale for an integrative and flexible systemic approach

It appears, therefore, that the evidence for the three main EBPs associated with CT in young people is
mixed, particularly when it comes to high-­risk and diverse populations with complex presentations, and
that engagement and premature dropout in particular can be a significant problem for those groups. This
reflects my practice experience of young people with CT who have often struggled to engage with these
treatments when offered them. I have some hypotheses in relation to these engagement difficulties:

• The significant attachment difficulties of young people with CT make family therapies such as FFT
and MST, where the therapist has to attend to the needs of multiple family members, too difficult

2
Throughout this article, I will use the word parent to denote either parent or carer.
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SYSTEMIC THERAPY WITH CHILDREN AND YOUNG PEOPLE WITH
COMPLEX TRAUMA     209

for them to cope with initially. This hypothesis is supported by research on improving engagement
with FFT which demonstrates that unequal alliances between therapist and family members is a
predictor of dropout (Collyer et al 2020; Robbins et al., 2003). Young people with CT may therefore
benefit from an individual therapy component to support their attachment difficulties and allow for
the development of a trusting relationship with the therapist;
• The significant dropout rates for TF-­CBT, which reflect dropout rates generally for child trauma-­
focused therapies (Wamser-­Nanney & Steinzor, 2017), are likely related to the emotional difficulty
of processing trauma, particularly for young people. Strategies that help children feel less stressed
in therapy are likely to aid engagement, and this may include using alternatives to talking, using
non-­clinical settings and attending to issues of power in the therapeutic relationship;
• Because of their attachment difficulties, young people with CT find it hard to trust and build rela-
tionships with people. A common complaint from young people I work with about their previous
experiences of therapy is of ‘someone I don't know asking me personal questions about my busi-
ness’. They need a significant amount of time (often months in my experience) to build a therapeutic
relationship and establish trust before any work of a challenging nature can take place.

It may be that a both/and approach is required that combines the benefits of the systemic and
family-­oriented approaches of MST/FFT with the benefits of the individual trauma-­focused approach
of TF-­CBT, as in-­depth support in both domains is usually required. Family therapy is needed to ad-
dress ongoing relational difficulties that maintain problematic behaviours, develop family resilience
and support family relationships with other systems. Individual therapy may be required as a safe
space where children can process their trauma, as aspects of this can be difficult to express in the
context of family therapy. This has been acknowledged by practitioners attempting to integrate the
processing of child trauma into family therapy (e.g., Kerig & Alexander, 2012). One reason for this
is that in many cases parents have been involved in the perpetration of the child's trauma. Even where
they were not perpetrators, though, they may sabotage the child recounting their trauma out of feeling
responsible in some way, or it may be overwhelming for them emotionally. The child may also be re-
luctant to tell their story out of fear of hurting their family. For these reasons, the child will often need
an individual space in which they can safely process their trauma, and parents will also need their own
individual work before the trauma can be thought about in a family context.
To summarise then, young people with CT and their families may benefit from long-­term therapy
with combinations of individual and family therapy sessions and using strategies to reduce emotional
dysregulation in therapy sessions and aid engagement. I have therefore developed an integrative ap-
proach that combines aspects of the main EBPs as well as specific strategies and aspects of other
therapeutic approaches (e.g. attachment-­based therapies, arts and play therapies) to support both en-
gagement and the therapeutic needs of my clients. An integrative and flexible approach for CT has
also been advocated by other practitioners. For example, Lanktree and Briere (2013) propose a model
that includes the main elements of TF-­CBT, a mix of individual and family sessions and facilitating
the child to form a secure attachment with the therapist. The approach this article is based on has
commonalities with that approach but uses a systemic framework and extensively uses systemic ideas
and techniques as summarised diagrammatically in Tables 1 and 2 and explored in more detail below.

Attachment

There is now a wealth of evidence supporting the importance of secure attachment in social and
emotional development, as summarised in a recent meta-­analysis by Groh et al. (2017). Attachment
210 |    COBBETT

TABLE 1 Theory elements

Attachment Post-­Milan systemic therapy Narrative therapy
Cognitive behavioural therapy Solution-­focused therapy Neurology/physiology

TABLE 2 Key practice elements

Attending to Developing Psychoeducation Processing trauma Individual and
aspects of emotional family sessions
power and regulation skills
difference
Activities, arts, Developing Developing hopes Strengthening Engaging with
play awareness for a preferred family wider systems
of personal future relationships –­ advocacy,
resources and resources empowerment

has become increasingly incorporated into systemic therapy in the form of a variety of attachment-­
informed systemic models that have influenced this approach. Vetere and Dallos (2008) describe how
systemic therapy can help deconstruct attachment narratives about self and relationships. Johnson
and Lee (2000) use emotionally focused family therapy to help parents address the unmet attach-
ment needs of their children. Byng-­Hall (2008) emphasises the importance of the attachment between
therapist and clients. He describes the role of the therapist as a secure base to facilitate the family
feeling safe enough to explore new ideas and ways of relating. He also highlights the need for the
therapist to be reflexive about how she interacts with the family, being sensitive to their emotional
state and thinking about how her behaviours might be interpreted. There is a growing understanding
of how emotionally attuned attachment experiences such as these become embedded at a neurologi-
cal level during childhood and also, similarly, the neurological consequences of environments where
children are not experiencing secure attachment (Feldman, 2017; Schore, 2013). Attachment experi-
ences shape the development of neural pathways in the brain so that securely attached children will
have different neural pathways encoding different patterns of thought, emotion, belief and behaviour
in comparison with insecurely attached children. Neuroplasticity also allows the brain to ‘rewire’
through the organisation of different neural pathways in the context of a new experience such as a
therapeutic relationship (Cozolino, 2010).
This approach contains two elements already alluded to which might be considered unconventional
from a systemic perspective. Firstly, long-­term work may well be necessary. My experience has been
that around 2 years represents sufficient time for clients to have an experience of therapy that is genu-
inely transformative and leads to sustained change, although sometimes this may be extended to 3 or
even more years. This gives children and their families enough time to develop trust, to safely process
complex traumatic issues, to consolidate progress and to have a thoughtful and planned ending. This
kind of timeframe is not completely unheard of in systemic therapy –­Byng-­Hall (1995) does describe
a similar length of time in his work but would only see families ten to twelve times within that period.
In the approach described in this article, families are typically seen thirty to forty times overall, some-
times more, with the frequency of sessions decreasing over time. Vetere and Sheehan (2020) have also
just edited a book describing the benefits of long-­term systemic therapy in which the length of time
needed to both build trust and resolve complex difficulties is highlighted throughout.
The other unconventional attachment element from a systemic lens is the inclusion of a significant
number of individual sessions for the child (and occasionally other family members) for the reasons
already described. If it fits with the wishes of the family, individual sessions are usually weekly to
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SYSTEMIC THERAPY WITH CHILDREN AND YOUNG PEOPLE WITH
COMPLEX TRAUMA     211

start with and then reduce in frequency as the work progresses and as family work begins. Parallel to
this individual work with the young person, work with the parents indirectly supports parent–­child
relationships, and everyone is prepared for conjoint family sessions.
One caveat in terms of working in an attachment-­based way from a systemic standpoint is that it
is important not to pathologise insecure attachment. Insecure attachment styles develop for very good
reasons, that is, to ensure that some of the child's developmental needs are met and that they protect
themselves as best they can. Insecure attachment is also common –­in one classic study (Hazan &
Shaver, 1987), it was found that only 56% of adults identified as having a secure attachment style.
Equally, insecure attachment does not always arise out of abuse and neglect; it can be the product, for
example, of an authoritarian parenting style. The contexts from which parenting styles and even abuse
and neglect arise are also relevant –­for example, poverty, inequality, prejudice, domestic violence,
mental health difficulties and family scripts about parenting all play a part, and it can be helpful to
explore how parents can resist some of those factors (whether historical or present). Equally, children
may develop a more helpful narrative about themselves and their lives if they can appreciate the con-
textual pressures impacting on parental behaviours.
A second caveat is related to what could be thought of as one of the founding principles of systemic
therapy, that is, the desire to support already existing relationships and avoid creating an unhelpful
dependency on the therapist. This approach involves the child (and the family to a lesser extent) form-
ing a temporary secure attachment to the therapist for the previously mentioned reasons. However, the
key word here is temporary. The attachment to the therapist is seen as a form of necessary ‘attachment
intensive care’, while work also takes place on strengthening the child's already existing attachments
until the therapeutic attachment is no longer needed. In this way, the attachment to the therapist tem-
porarily supplements but does not undermine family attachments.

Non-­verbal, physical and creative interactive activities

Children and adolescents are at a developmental stage where it may be difficult for them to just sit and
talk, particularly about difficult and emotional topics. This may be for a number of reasons including
cognitive limitations, difficulties regulating emotions and simply a greater need to move around than
adults. These differences are exaggerated by CT because of its impact on neurological and psycholog-
ical development. It is important in terms of engagement that young people feel sufficiently comfort-
able in therapy sessions and that they can find a way to express themselves and be heard. It has been
noted that there can be a discrepancy in family therapy between the story told [using Pearce’s (2009)
concept] of including children, and the story lived in which they are often excluded either literally
by not being invited or relationally within sessions by not being able to contribute as much as adults
(Rober, 2008). This is even more the case with young people who express their difficulties through
externalising behaviours (Johnson & Thomas, 1999), which is common with young people who have
experienced CT. This seems related to the reliance on verbal interaction, and in this approach a vari-
ety of interactional activities enable young people to have a voice in sessions and help them engage.
Other authors have advocated the use of the arts and play in systemic therapy (Armstrong & Simpson,
2002; Rotter & Bush, 2000; Wilson, 2016). In this approach, a broader range of activities is involved,
and they play a primary role. The nature of the activities used depends on the interest and age of the
young person but can include playing musical instruments, listening to pre-­recorded music, art, dra-
matic roleplay, expressive play with figures, sport and physical play, riding bicycles, weight training,
using a punch bag, woodwork, watching video material and playing games such as hide and seek
or cards. The therapist explains from the start about the different options available, and the therapy
212 |    COBBETT

rooms contain a wide range of resources to support such activities which the young people themselves
are free to choose from. Usually, children are able to decide for themselves what they need to do in
therapy sessions, and the therapist follows their lead. Occasionally though, the therapist may suggest
particular activities because of a particular therapeutic benefit or because the child seems stuck or
unhelpfully anxious. Before family work begins, parents are supported to appreciate the developmen-
tal differences between children and adults and how including non-­verbal activities can help their
children engage and find a voice. Parents vary in their level of comfort in engaging in such activities,
and there is usually a process of negotiation amongst family members in terms of the balance of talk
and other activities.
Often these activities involve a significant element of metaphor, that is, they can illustrate aspects
of clients’ lives in a symbolic way, and this can be useful therapeutically. It can sometimes feel less
threatening and can be easier cognitively for children to explore their experiences metaphorically
using expressive activities rather than verbally. Also, the experiential nature of expressive activities
can have a profoundly transformative nature of their own.

In family sessions with two young brothers and their mother3, the majority of the work
was based around narrative play with figures initiated by the boys. The mother also par-
ticipated in the play, and I used systemic techniques to support thinking about the issues
the stories revealed, either through verbal offerings or joining in the play or a combina-
tion of both. The family had experienced domestic violence from the boys’ father, and the
mother had also experienced similar abuse as a child herself. The mother had a correc-
tive script (Byng-­Hall, 1985) operating which prevented her from appropriately disci-
plining her sons out of a fear of abusing them, and there were also gender beliefs that
emphasised male strength in a way that seemed to be restricting the family. The play
stories they initiated were incredibly rich and full of meaning and clearly expressed as-
pects of their lived experience, for example, containing a lot of brutal violence in the
early stages. There was a sense of hopelessness and of being stuck, but as the sessions
progressed, I used curiosity to gradually facilitate the emergence of subjugated narra-
tives of hope and resilience using questions such as ‘Has it always been like this?’ or
‘Who can help?’ We noticed circularities in the play; for example, the tendency of one
side in a war story to mistrust the other led to the other side becoming more aggressive
and attacking the first side even more, which in turn led to more mistrust. When one side
risked trusting the other with the encouragement of a helper figure I introduced into the
play, initially it was sabotaged, but the second time something different happened, and
the old circularity was broken. Gradually, alternative narratives emerged in the play
around compromise, identifying needs, developing resources, non-­violent assertiveness,
discovering the strengths of female characters and hope for a peaceful future. In verbal
conversation, we moved between this metaphorical world and the real world through
making links between the play and their actual lives. The play activity acted as an essen-
tial form of communication for the boys in terms of putting their trauma into a narrative
that could be processed and then developing new meanings and possibilities.

Some of these activities can also act as emotion regulation tools which can be helpful in terms of both
keeping therapy sessions safe and developing new skills.

3
Permission has been sought for all clinical material presented which has also been anonymised.
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SYSTEMIC THERAPY WITH CHILDREN AND YOUNG PEOPLE WITH
COMPLEX TRAUMA     213

An adolescent who had difficulties managing violent and aggressive behaviours used a
punch bag in the therapy room to help emotionally regulate himself during individual
and family therapy sessions. It helped him remain safely engaged in the sessions but also
led to the family buying a punch bag that he could use at home as a strategy to defuse
conflict situations. This enabled a change in circular patterns of behaviour, a difference
that provoked a different response from his parents in contrast to the way things would
normally escalate.

The provision of non-­verbal means of interacting also relates to issues of power. Many client families
have had multiple experiences of disempowerment in their lives and are sensitised to power imbalances
in relationships including the therapeutic relationship. Therapists have often had privileges in their lives
that afford them good verbal fluency which may be experienced as intimidating. Non-­verbal activities can
act as equalisers that create some balance in the power dynamic between therapist and clients, particularly
young clients and especially if these are tailored to their interests. They can also reveal client resources
and strengths.

In a home-­based family session, a young man was fixing his bike while we talked. His
mother reprimanded him for not paying attention to me. I offered a reframe (Watzlawick et
al., 1974) by asking her if sometimes he might find it easier to concentrate on a conversation
while he did something, and she acknowledged that this was often the case. I confessed to my
ignorance of bike mechanics and lamented the fact that I had to take my bike to a repair shop
for the simple task of replacing an inner tube. He responded as I had hoped and enthusias-
tically showed me how I could replace it, for which I expressed my admiration of his skills
and my appreciation of his help. His mother, moved by my response, was able to recognise
that practical skills and helping others were two strengths that he possessed, which was a
difference from her usual problem-­saturated view of him, and we went on to explore how
those strengths might be developed.

Many of the previously listed activities can be done in combination with talking. For example, in terms
of using pre-­recorded music, young people can be invited to play songs or raps that they like, which can
then be used as a relatively indirect way of discussing relevant difficulties as they invariably choose songs
that reflect aspects of their personal experience. Some activities obviously require careful preparation,
for example, the use of woodwork needing familiarisation with the tools and training in relevant areas of
health and safety. I would also advise a degree of care when it comes to the expressive arts and imaginative
play as although this kind of expression can be easier for children, it can also sometimes be an intense
emotional experience. Additional training, such as an introductory course in play therapy or one of the arts
therapies, can be helpful when using such media.
When considering the psychological safety of activities, Mason’s (1993) principle of safe uncer-
tainty can be a useful guide and may be thought of in relation to the whole therapist–­client system.
A degree of therapist uncertainty and even discomfort can be beneficial to the therapeutic process,
but if the therapist feels unsafe then it is likely that clients will also feel unsafe. This self-­reflexivity,
combined with collaboratively checking in with clients’ experience of activities, can be a useful guide.
Trusting young people's instinctive understanding of what they need and co-­directing the content and
flow of sessions with them also helps to keep activities within the realm of safety.
214 |    COBBETT

A boy I had been playing football with suggested in a session that he could teach me
some skills (in response to my pathetic performance!). I was unsure if it might take the
therapy in an unhelpful direction, but I decided to agree, and we then spent four sessions
in this mode with him essentially taking on a football coach role. This turned out to be
highly productive therapeutically. He experienced himself in a new role, and we identi-
fied skills he used in that role which helped to shift some of the narratives he had about
himself. It also triggered memories of a supportive coach who had trained him, and this
positive relationship provided some useful resources. The experience also strengthened
the therapeutic relationship in that he saw me take myself out of my comfort zone, and
this encouraged him to challenge himself in future sessions. My worries about our work
changing course in an unhelpful way were unfounded, and once he had experienced what
he needed, we moved on to something else.

Using non-­clinical settings

Therapy provision in non-­clinical settings such as schools can offer advantages in terms of helping
marginalised young people and their families to engage successfully (Aggett et al., 2015; Anderson
et al., 2017; Pettitt, 2003). Locating therapy in school avoids the stigma often associated with men-
tal health clinics. Young people also spend a significant proportion of their life in school, and it is
often seen as a safe place, particularly where there are supportive relationships with school staff.
Many schools prioritise building consistent supportive relationships with parents so they may be
seen as trusted places by families too. Working in a school also affords the possibility of a therapist
working closely with teaching and support staff to develop effective wrap-­around care for a child.
This can include training on areas such as trauma, attachment and systemic ideas for school staff,
which can help their understanding of students and equip them with useful skills. The effectiveness
of school-­based therapy can also be augmented by taking proactive steps to integrate the provi-
sion into the overall school culture so that it becomes a familiar entity that is owned by the school
community.
In line with FFT and MST, this approach also often includes therapy sessions in the home. This
can be helpful where parents have difficulties attending the school and young people have disengaged
from education. The therapist's efforts in travelling to the home can demonstrate their commitment,
thus building trust, although there is also a need to check that families feel they have a genuine choice
regarding this and that their right to privacy is not invaded. The permission-­seeking stance described
by Aggett et al. (2015) can be helpful in this respect.
Other locations may be useful for outside activities such as cycling, walking or playing sport. Some
clients also feel safer and more relaxed in a public or outside space, and such environments can make
it easier for them to engage in therapeutic conversations. Many young people also find that doing
something like playing football, which is impossible in a room, helps them emotionally self-­regulate,
and this helps them to remain engaged. Issues of privacy that arise when clients start talking about
sensitive issues in public spaces can be addressed by checking in with them to see if they are still
comfortable with the environment and whether they would prefer to save that conversation for a more
private space. Often this kind of work takes place in the early relationship-­building stage, though, and
does not involve intensely personal conversations. This approach prioritises respect for clients’ differ-
ent needs and seeks to co-­create a suitable therapy space accordingly.
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SYSTEMIC THERAPY WITH CHILDREN AND YOUNG PEOPLE WITH
COMPLEX TRAUMA     215

Male-­friendly practice

As mentioned above, this approach has been developed from practice experience largely with boys,
young men and their families. Males are notoriously difficult to engage in mental health support, and
their use of services is significantly lower than females’ (Rice et al., 2018). A major contributory
factor seems to be dominant cultural narratives about masculinity which often convey disapproval of
expressing vulnerable emotions or seeking help (Evans et al., 2011).
The use of activities and informal settings as described above in relation to children can also have
benefits in relation to engaging males by facilitating a relaxed atmosphere that can reduce the sense of
threat to masculine identity. Other factors that can be helpful include:

• Initially at least, not overtly labelling the support offered as ‘therapy’ to help reduce feelings of
stigma and shame;
• Using a down-­to-­earth approach with lots of humour. This can even include banter (i.e., mutual
playful teasing), which is frequently used by males in the UK as a way of bonding. If used sensi-
tively, when a degree of trust has already been established, it can further strengthen the therapeutic
alliance and can also be used to playfully challenge current beliefs;
• Using self-­disclosure. This emphasises a genuineness in the therapeutic relationship, and particu-
larly for male therapists, it can be helpful to model that it is acceptable to talk about difficult expe-
riences and vulnerable emotions.

The work around male identity involves exploring beliefs about masculinity that may be restrictive.
Using a variety of systemic therapy techniques can help clients explore the origins of these beliefs, the
meaning they have and difference in beliefs at different levels of context.

When working alongside a boy who had difficulties managing his violent behaviours or
expressing any vulnerabilities, we explored the injustice of males not being able to admit
to having vulnerable feelings and the impact this has on their lives. I also helped him
uncover subjugated narratives; for example, he respected his male mentor who was help-
fully modelling expressing his own vulnerable feelings to the boy openly. In the context
of an absent father, we thought about positioning (Harre et al., 2003), and in a family
session, his mother realised she needed to give him permission to be a child and not feel
responsible for the family. This involved her attending to some of his unmet attachment
needs through simple gestures of care. We explored the impact of the violent male role
models in his life and how he wanted a different script in terms of wanting to be a differ-
ent father to the abusive one he had experienced. I used externalising (White & Epston,
1990) to help him think about his relationship to violence and how he could develop
agency over it. This does not mean that I colluded with him in terms of him not taking re-
sponsibility for his violence. I have found that externalising can be helpful in developing
flexibility in males in their beliefs about violence and actually promotes responsibility
because they develop the idea that they are not inherently violent but have a relationship
with violence that they can choose to change. I also drew again on positioning theory
to help him think about how he was influenced by family scripts and cultural narratives
from his Gypsy background in relation to the acceptability or not of violence in different
situations. He was able to choose to shift his position on a spectrum of violence so that
he would still use violence to defend himself, but would not proactively use violence, and
he would try to use alternative strategies to seeking revenge.
216 |    COBBETT

Working-­class-­friendly practice

The traditional terms working class and middle class shall somewhat reluctantly be used here to
describe people who have different levels of socio-­economic power and to also encompass the pos-
sibility of shared cultural values and practices. This reluctance comes from an awareness that although
some parents in this client group still identify as working-­class, the majority of the young people do
not and prefer terms such as 'street' or 'hood'.
Savage (2015) identifies three components to class: economic, cultural and social (social refer-
ring to the social networks that people have). This multi-­layered definition of class seems helpful in
relation to complex trauma. These clients have often been affected, indirectly and directly, by socio-­
economic disadvantage in traumatic ways, and this is part of the experience that they bring to therapy.
At the same time, awareness of the cultural components of class is important in terms of how we build
collaborative relationships together and avoid yet more experiences of exclusion.
Working-­class people are consistently under-­reached by mental health and therapeutic services,
although they have a much higher risk of developing mental health difficulties (Santiago et al., 2013).
Coming from a low socio-­economic status background also significantly increases the risk of young
people not engaging with therapy (De Haan et al., 2015). Barriers to accessing support include previ-
ous negative experiences of professional help, a perception of help services as middle-­class oriented,
cultural narratives (e.g. around being strong and ‘getting on with it’) and parents fearing they may
lose their children. There is surprisingly little research into the subjective experience of working-­class
people offered therapy and how we may improve that experience, even in the systemic field. However,
a few authors (e.g. Santiago et al., 2013; Thompson et al., 2012; Ware et al., 2004) have researched this
and made recommendations. These are also part of my own practice and include:

• Providing gestures of care like drinks;

• Proactively reaching out to clients and facilitating attendance in terms of practicalities;
• Directly addressing issues of class in therapy and attempting to understand clients’ class-­based
experiences with empathy. Acknowledging differences between therapist and clients but also at-
tempting to discover the universal in common ground;
• Being flexible and available;
• Providing education about therapy and the model used;
• Working collaboratively with opportunity for client input into therapeutic process;
• Acting as an advocate or ally to clients in helping them in the community outside of the therapy
time.

The last point about advocacy is particularly important with these clients. They often reach a point
of giving up on trying to be heard by the systems around them, and there are power structures that
make this difficult too. Therapists have an ethical duty to use their positions of power to ensure that
clients’ needs and rights are voiced as much as possible so that they receive the support they need and
potential harms against them are minimised. An example of this is proactively contacting youth courts
with information about young people's psychological difficulties and how that might impact on their
offending as well as the possible harms to them of custody. It can also involve liaising with housing
and special educational needs departments. These actions are powerful in terms of building trust and
demonstrating the therapist's understanding of the difficulties clients face because of their position in
society. However, care needs to be taken that this is offered in a genuinely empowering way so that
advocacy is balanced with supporting clients to strengthen their own voice.
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SYSTEMIC THERAPY WITH CHILDREN AND YOUNG PEOPLE WITH
COMPLEX TRAUMA     217

Minority-­ethnic-­friendly practice

There is a disproportionate representation of young people who are minority ethnic within the SEMH
population (Cooper, 2006). The reasons for this are unclear, but it seems reasonable to hypothesise
that a significant factor could be that being from a minority ethnic background is correlated with low
socio-­economic status (Platt, 2007; Modood et al., 1997). Minority ethnic people are also underserved
when it comes to accessing psychotherapy, and research has indicated that barriers may be overcome
through a number of practices (Aggarwal et al., 2016; Keating & Robertson, 2004; Mclean et al.,
2003; Memon et al., 2016). These include:

• Attempting to bridge different cultural beliefs about mental health;

• Discussing experiences and different beliefs related to ethnicity and culture;
• Proactively providing space for and empathising with experiences of racism;
• Acknowledging and discussing ethnicity-­based anxieties about accessing therapy in relation to
wider issues, for example, that minority ethnic people are more likely to be detained against their
will or given drug treatments or even die when they access mental health services;
• Acknowledging and exploring ethnic difference between clients and therapist;
• Using non-­clinical community settings and avoiding an overly medicalised stance which may feel
stigmatising.

I would add that the principle of sensitively managed advocacy, as mentioned above in relation
to working-­class families, can be important for minority ethnic families too in terms of helping them
resist discriminatory power structures.

In sessions with a Black Dominican adolescent and his Black Jamaican adoptive father,
it was important for me to acknowledge the trauma he had experienced as a result of
what he perceived as constant racist harassment by the police and also acknowledging
my difficulty in truly understanding the totality of that experience as a White person.
Respectfully finding space for this narrative also allowed the uncovering of subjugated
narratives about his father’s experience of police racism and facilitated the growth of
empathy in the father for his son’s struggles. They were also able to draw on the father’s
experience to think about how the boy could manage interactions with the police in a way
where he could maintain some power and self-­respect without risking being arrested.

These kinds of discussion can also be helped by the use of self-­reflexivity with regard to the therapist's
ethnicity and their different experiences and beliefs in comparison with clients.

Psychoeducation

More will be said in the next section about the general use of therapist expertise in the context of
systemic therapy, but a particular aspect of this is the use of psychoeducation where explanations can
be offered to clients about trauma, attachment and the science of both in terms of neurology and other
biological factors, a practice drawn from TF-­CBT.
218 |    COBBETT

In a family session with an adolescent boy with experience of abuse who had been po-
sitioned as the ‘bad child’ by his family and previous mainstream schools, I asked if I
could offer an alternative narrative in the form of information about trauma and how
this affects the brain, body and behaviours as a result. The boy enthusiastically identified
with the information which resonated with his experience of constantly feeling under
threat and needing to fight to protect himself. This led to new meanings being appre-
ciated that helped his parents reframe his challenging behaviours and respond to them
more empathically in a way which then led to those behaviours reducing. The concept of
neuroplasticity also offered the family hope in that there was a scientific explanation for
how those biological effects (and the behaviours) could reduce over time in the context
of new healing interactions. This was particularly important for this young man who had
essentially given up hope of a positive future and was entrenched in dangerous criminal
activity.

From a systemic point of view, psychoeducation can thus act as an empowering source of new narra-
tives, meanings and hope for a preferred future.

Integration of elements

In this practice model, the various therapeutic elements do not necessarily follow a particular order,
although broadly in line with the EBPs, there is usually a progression from engagement/relationship
building and stabilisation/risk reduction to the more challenging aspects of the work, including trauma
processing and promotion of change in behaviours, and then ending in consolidation of progress,
linking to community support and preparation for ending. The therapy route is always agreed collabo-
ratively though, and with respect for client self-­knowledge. In terms of safety, it is often preferable to
build resources and develop emotional regulation skills first as these can often help to stabilise clients
who are in high-­risk situations. However, sometimes children are so desperate to express the story
of their trauma that they spontaneously start working on this element at the start of therapy. I allow
them to bring what they want to their therapy, and this comes from a position of respect for client self-­
expertise. In these cases, it is possible to support the child's need to recount their trauma while also
including resource-­building elements at the same time. Safety can also be enhanced through collabo-
ratively checking in with clients about how they are experiencing their therapy sessions and agreeing
on safety structures such as time-­out from an emotionally intense conversation or activity.
The various elements available are outlined by the therapist at the start of therapy, and then we
check in regularly to discuss what has been useful and what has not been so useful so far and adjust
accordingly. There is also flexibility in terms of whether the family indicates a preference for therapy
which is more collaborative and co-­evolved or whether professional knowledge is sought in a more
explicit way. This flexible approach to the use of expertise in family therapy is similarly advocated by
Laitila (2009), who discusses a reflexive both/and approach to using acquired knowledge expertise
and relational expertise, depending on the situation.

Evaluation of practice

In the practice on which this approach is drawn, Strengths and Difficulties Questionnaires (Goodman,
1997) are used to assess individual progress with young people's social, emotional and behavioural
 |
SYSTEMIC THERAPY WITH CHILDREN AND YOUNG PEOPLE WITH
COMPLEX TRAUMA     219

difficulties. SCORE-­15 (Stratton et al., 2010) is used to measure progress in family functioning. These
data are amalgamated on an annual basis to provide average figures, which have consistently shown
that both individual young people and families make significant progress using this approach. The
data are shared with school staff annually so that they have confidence in the therapy provision and
may also be shared with clients. Future research could include a waiting list control group to allow for
a more rigorous evaluation of effectiveness.

Summary

The approach I am describing is based on my experience of working with young people with CT and
their families, drawing also upon relevant research in this area. It is a synthesis of elements that are
evidence-­based in themselves but as a loose integrative package offers a form of therapeutic support
that addresses the whole complexity of need of young people with CT and their families, rather than
focusing on a narrow set of diagnostic symptoms. The emphasis on maximising accessibility and en-
gagement with respect to aspects of difference and power is also key and I think an ethical imperative
when working alongside this client group. Marginalised young people and their families have expe-
rienced multiple forms of disempowerment and silencing in their lives and of having ‘interventions’
done to them. I feel it is important that their experience of therapy offers something different which
is truly collaborative, recognises their expertise and is experienced as a genuine human encounter.

ORCID
Steve Cobbett https://orcid.org/0000-0002-9571-9549

R E F E R E NC E S
Aggarwal, N.K., Pieh, M.C., Dixon, L., Guarnaccia, P., Alegria, M. & Lewis-­Fernandez, R. (2016) Clinician descrip-
tions of communication strategies to improve treatment engagement by racial/ethnic minorities in mental health
services: a systematic review. Patient Education and Counseling, 99(2), 198–­209.
Aggett, P., Swainson, M. & Tapsell, D. (2015) ‘Seeking permission’: an interviewing stance for finding connection with
hard to reach families. Journal of Family Therapy, 37(2), 190–­209.
Anderson, J.K., Howarth, E., Vainre, M., Jones, P. & Humphrey, A. (2017) A scoping literature review of service-­level
barriers for access and engagement with mental health services for children and young people. Children and Youth
Services Review, 77, 164–­176.
Armstrong, S.A. & Simpson, C.S. (2002). Expressive arts in family therapy: including young children in the process
Stephen A. Armstrong and Chris S. Simpson. TCA Journal, 30(2), 2–­9.
Boxer, P. (2011) Negative peer involvement in multisystemic therapy for the treatment of youth problem behav-
ior: exploring outcome and process variables in “real-­world” practice. Journal of Clinical Child & Adolescent
Psychology, 40(6), 848–­854.
Briere, J. & Lanktree, C. (2008) Integrative treatment of complex trauma for adolescents (ITCT-­A): a guide for the
treatment of multiply-­traumatized youth. Retrieved from JohnBriere. com.
Brown, E.R., Khan, L. & Parsonage, M. (2012) A chance to change. London: Centre for Mental Health.
Byng-­Hall, J. (1985) The family script: a useful bridge between theory and practice. Journal of Family Therapy, 7,
301–­305.
Byng-­Hall, J. (1995) Creating a secure family base: some implications of attachment theory for family therapy. Family
process, 34(1), 45–­58.
Byng-­Hall, J. (2008) The crucial roles of attachment in family therapy. Journal of Family Therapy, 30(2), 129–­146.
Cary, C.E. & McMillen, J.C. (2012) The data behind the dissemination: a systematic review of trauma-­focused cognitive
behavioral therapy for use with children and youth. Children and Youth Services Review, 34(4), 748–­757.
220 |    COBBETT

Chia-­Chen Chen, A., Keith, V.M., Airriess, C., Li, W. & Leong, K.J. (2007) Economic vulnerability, discrimination,
and Hurricane Katrina: health among Black Katrina survivors in eastern New Orleans. Journal of the American
Psychiatric Nurses Association, 13(5), 257–­266.
Cohen, J.A. & Mannarino, A.P. (2011). TF-­CBT for youth in residential treatment facilities: preliminary treatment out-
come findings. Data reported in NIMH grant application, (R01MH95208).
Cohen, J.A., Mannarino, A.P. & Deblinger, E. (2006) Treating trauma and traumatic grief in children and adolescents.
New York: Guilford Press.
Cohen, J.A., Mannarino, A.P., Kliethermes, M. & Murray, L.A. (2012) Trauma-­focused CBT for youth with complex
trauma. Child Abuse & Neglect, 36(6), 528–­541.
Collins, K.S., Strieder, F.H., DePanfilis, D., Tabor, M., Freeman, P.A.C., Linde, L. et al. (2011) Trauma adapted family
connections: reducing developmental and complex trauma symptomatology to prevent child abuse and neglect.
Child Welfare, 90(6), 29.
Collyer, H., Eisler, I. & Woolgar, M. (2020) Parent and youth perspectives and retention in functional family therapy.
Family Process, 60(2), 316-­330.
Cook, A., Spinazzola, J., Ford, J., Lanktree, C., Blaustein, M., Cloitre, M. et al. (2005) Complex trauma in children and
adolescents. Psychiatric Annals, 35, 390–­398.
Cooper, P. (2006) Supporting minority ethnic children and adolescents with social, emotional, and behavioral diffi-
culties in the United Kingdom. Preventing School Failure: Alternative Education for Children and Youth, 50(2),
21–­28.
Cooper, P. (2010) Social, emotional and behavioural difficulties in young people: the challenge for policy makers. The
International Journal of Emotional Education, 2(1), 4–­16.
Cozolino, L. (2010) The neuroscience of psychotherapy: healing the social brain (Norton Series on Interpersonal
Neurobiology). New York: WW Norton & Company.
Curtis, N.M., Ronan, K.R. & Borduin, C.M. (2004) Multisystemic treatment: a meta-­analysis of outcome studies.
Journal of Family Psychology, 18(3), 411.
Darnell, A.J. & Schuler, M.S. (2015) Quasi-­experimental study of Functional Family Therapy effectiveness for juvenile
justice aftercare in a racially and ethnically diverse community sample. Children and Youth Services Review, 50,
75–­82.
Davidson, J. (2008) Children and young people in mind: the final report of the National CAMHS Review. London:
Department of Health.
De Haan, A.M., Boon, A.E., Vermeiren, R.R., Hoeve, M. & de Jong, J.T. (2015) Ethnic background, socioeconomic
status, and problem severity as dropout risk factors in psychotherapy with youth. Child & Youth Care Forum,
44(1), 1–­16.
Department for Education. (2014) Special educational needs and disability code of practice: 0–­25 years. London:
HMSO.
Department for Education. (2020a) SEN statistics for England. London: Department for Education. Retrieved from
https://www.gov.uk/gover​nment/​stati​stics/​speci​al-­educa​tiona​l-­needs​-­in-­engla​nd-­jasnu​ary-­2020
Department for Education. (2020b) Special educational needs in England. London: Department for Education. Retrieved
from https://explo​re-­educa​tion-­stati​stics.servi​ce.gov.uk/find-­stati​stics/​speci​al-­educa​tiona​l-­needs​-­in-­england
Dulmus, C.N., Ely, G. & Wodarski, J.S. (2004) Children's psychological response to parental victimization: how do girls
and boys differ? Journal of Human Behaviour in the Social Environment, 7(3–­4), 23–­36.
Early Intervention Foundation. (2019) Guidebook: functional family therapy. London: Early Intervention Foundation.
Retrieved from https://guide​book.eif.org.uk/progr​amme/funct​ional​-­famil​y-­therapy
Evans, J., Frank, B., Oliffe, J.L. & Gregory, D. (2011) Health, illness, men and masculinities (HIMM): a theoretical
framework for understanding men and their health. Journal of Men's Health, 8(1), 7–­15.
Feldman, R. (2017) The neurobiology of human attachments. Trends in Cognitive Sciences, 21(2), 80–­99.
Fergusson, D.M. & Horwood, L.J. (1998) Early conduct problems and later life opportunities. Journal of Child
Psychology and Psychiatry, 39(8), 1097–­1108.
Goodman, R. (1997) The strengths and difficulties questionnaire: a research note. Journal of Child Psychology and
Psychiatry, 38, 581–­586.
Groh, A.M., Fearon, R.M.P., van IJzendoorn, M.H., Bakermans-­Kranenburg, M.J. & Roisman, G.I. (2017) Attachment
in the early life course: meta-­analytic evidence for its role in socioemotional development. Child Development
Perspectives, 11(1), 70–­76.
 |
SYSTEMIC THERAPY WITH CHILDREN AND YOUNG PEOPLE WITH
COMPLEX TRAUMA     221

Harré, R., Harré, R., Moghaddam, F.M. & Moghaddam, F. (Eds.) (2003) The self and others: positioning individuals
and groups in personal, political, and cultural contexts. Westport: Greenwood Publishing Group.
Hartnett, D., Carr, A., Hamilton, E. & O'Reilly, G. (2017) The effectiveness of functional family therapy for adolescent
behavioral and substance misuse problems: a meta-­analysis. Family Process, 56(3), 607–­619.
Hazan, C. & Shaver, P. (1987) Romantic love conceptualized as an attachment process. Journal of Personality and
Social Psychology, 52(3), 511–­552.
Henggeler, S.W. & Sheidow, A.J. (2003) Conduct disorder and delinquency. Journal of Marital and Family Therapy,
29(4), 505–­522.
Holt, L., Bowlby, S. & Lea, J. (2019) Disability, special educational needs, class, capitals, and segregation in schools: a
population geography perspective. Population, Space and Place, 25(4), e2229.
Humayun, S., Herlitz, L., Chesnokov, M., Doolan, M., Landau, S. & Scott, S. (2017) Randomized controlled trial of
Functional Family Therapy for offending and antisocial behavior in UK youth. Journal of Child Psychology and
Psychiatry, 58(9), 1023–­1032.
Johnson, L. & Thomas, V. (1999) Influences on the inclusion of children in family therapy: brief report. Journal of
Marital and Family Therapy, 25(1), 117–­123.
Johnson, S.M. & Lee, A.C. (2000) Emotionally focused family therapy: restructuring attachment. In: Bailey, C.E. (Ed.)
Children in therapy: using the family as a resource. New York, NY: Norton, pp. 112–­136.
Keating, F. & Robertson, D. (2004) Fear, black people and mental illness: a vicious circle? Health & Social Care in the
Community, 12(5), 439–­447.
Kerig, P.K. & Alexander, J.F. (2012) Family matters: integrating trauma treatment into functional family therapy for
traumatized delinquent youth. Journal of Child & Adolescent Trauma, 5(3), 205–­223.
Kliethermes, M., Schacht, M. & Drewry, K. (2014) Complex trauma. Child and Adolescent Psychiatric Clinics, 23(2),
339–­361.
Laitila, A. (2009) The expertise question revisited: horizontal and vertical expertise. Contemporary Family Therapy,
31(4), 239–­250.
Lanktree, C. & Briere, J. (2013) Integrative treatment of complex trauma. In: Ford, J.D. & Courtois, C.A. (Eds.) Treating
complex traumatic stress disorders in children and adolescents: scientific foundations and therapeutic models.
New York: Guilford Press, pp. 143–­161.
Lannamann, J.W. & McNamee, S. (2020) Unsettling trauma: from individual pathology to social pathology. Journal of
Family Therapy, 42(3), 328–­346.
Leenarts, L.E., Diehle, J., Doreleijers, T.A., Jansma, E.P. & Lindauer, R.J. (2013) Evidence-­based treatments for chil-
dren with trauma-­related psychopathology as a result of childhood maltreatment: a systematic review. European
Child & Adolescent Psychiatry, 22(5), 269–­283.
Littell, J.H. (2005) Lessons from a systematic review of effects of multisystemic therapy. Children and Youth Services
Review, 27(4), 445–­463.
Littell, J.H. (2006) The case for multisystemic therapy: evidence or orthodoxy? Children and Youth Services Review,
28(4), 458–­472.
Martel, M.M. (2013) Sexual selection and sex differences in the prevalence of childhood externalizing and adolescent
internalizing disorders. Psychological Bulletin, 139(6), 1221.
Mason, B. (1993) Towards positions of safe uncertainty. Human Systems, 4, 189–­200.
May-­Chahal, C. & Cawson, P. (2005) Measuring child maltreatment in the United Kingdom: a study of the prevalence
of child abuse and neglect. Child Abuse & Neglect, 29(9), 969–­984.
Mclean, C., Campbell, C. & Cornish, F. (2003) African-­Caribbean interactions with mental health services in the UK:
experiences and expectations of exclusion as (re) productive of health inequalities. Social Science & Medicine,
56(3), 657–­669.
Memon, A., Taylor, K., Mohebati, L.M., Sundin, J., Cooper, M., Scanlon, T. et al. (2016) Perceived barriers to access-
ing mental health services among black and minority ethnic (BME) communities: a qualitative study in Southeast
England. British Medical Journal Open, 6(11), e012337.
Modood, T., Berthoud, R., Lakey, J., Nazroo, J., Smith, P., Virdee, S. et al. (1997) Ethnic minorities in Britain: diversity
and disadvantage (No. 843). London: Policy Studies Institute.
Pearce, W.B. (2009) Making social worlds: a communication perspective. Chichester: John Wiley & Sons.
Pettitt, B. (2003) Effective joint working between child and adolescent mental health services (CAMHS) and schools.
London: Department for Education and Skills.
222 |    COBBETT

Platt, L. (2007) Poverty and ethnicity in the UK (Vol. 2059). Bristol: Policy Press.
Rawles, P.D. (2010). The Link between poverty, the proliferation of violence and the development of traumatic stress
among urban youth in the United States to school violence: a trauma informed, social justice approach to school
violence. In Forum on Public Policy Online (Vol. 2010, No. 4). Oxford Round Table. 406 West Florida Avenue,
Urbana, IL 61801.
Rice, S.M., Purcell, R. & McGorry, P.D. (2018) Adolescent and young adult male mental health: transforming system
failures into proactive models of engagement. Journal of Adolescent Health, 62(3), S9–­S17.
Robbins, M.S., Turner, C.W., Alexander, J.F. & Perez, G.A. (2003) Alliance and dropout in family therapy for adoles-
cents with behavior problems: individual and systemic effects. Journal of Family Psychology, 17(4), 534.
Rober, P. (2008) Being there, experiencing and creating space for dialogue: about working with children in family ther-
apy. Journal of Family Therapy, 30(4), 465–­477.
Rosenfield, S. (2000) Gender and dimensions of the self: implications for internalizing and externalizing behavior.
In: Frank, E. (Ed.) American psychopathological association series. Gender and its effects on psychopathology.
Washington: American Psychiatric Publishing Inc., pp. 23–­36.
Rotter, J.C. & Bush, M.V. (2000) Play and family therapy. The Family Journal, 8(2), 172–­176.
Santiago, C.D., Kaltman, S. & Miranda, J. (2013) Poverty and mental health: how do low-­income adults and children
fare in psychotherapy? Journal of Clinical Psychology, 69(2), 115–­126.
Savage, M. (2015) Social class in the 21st century. London: Penguin UK.
Schneider, S.J., Grilli, S.F. & Schneider, J.R. (2013) Evidence-­based treatments for traumatized children and adoles-
cents. Current Psychiatry Reports, 15(1), 332.
Schore, A.N. (2013) Relational trauma, brain development, and dissociation. In: Ford, J.D. & Courtois, C.A. (Eds.)
Treating complex traumatic stress disorders in children and adolescents: scientific foundations and therapeutic
models. New York: Guilford Press, pp. 143–­161.
Stratton, P., Bland, J., Janes, E. & Lask, J. (2010) Developing an indicator of family function and a practicable outcome
measure for systemic family and couple therapy: the SCORE. Journal of Family Therapy, 32, 232–­258.
Susman, E.J., Nottelmann, E.D., Inoff-­Germain, G., Dorn, L.D. & Chrousos, G.P. (1987) Hormonal influences on
aspects of psychological development during adolescence. Journal of Adolescent Health Care, 8(6), 492–­504.
Thompson, M.N., Cole, O.D. & Nitzarim, R.S. (2012) Recognizing social class in the psychotherapy relationship: a
grounded theory exploration of low-­income clients. Journal of Counseling Psychology, 59(2), 208.
Van der Kolk, B.A. (2017) Developmental trauma disorder: toward a rational diagnosis for children with complex
trauma histories. Psychiatric Annals, 35(5), 401–­408.
Van der Stouwe, T., Asscher, J.J., Stams, G.J.J., Deković, M. & van der Laan, P.H. (2014) The effectiveness of multisys-
temic therapy (MST): a meta-­analysis. Clinical Psychology Review, 34(6), 468–­481.
Vetere, A. & Dallos, R. (2008) Systemic therapy and attachment narratives. Journal of Family Therapy, 30(4), 374–­385.
Vetere, A. & Sheehan, J. (2020) Long term systemic therapy. Switzerland: Springer.
Wamser-­Nanney, R. & Steinzor, C.E. (2017) Factors related to attrition from trauma-­focused cognitive behavioral ther-
apy. Child Abuse & Neglect, 66, 73–­83.
Ware, N.C., Tugenberg, T. & Dickey, B. (2004) Practitioner relationships and quality of care for low-­income persons
with serious mental illness. Psychiatric Services, 55(5), 555–­559.
Watkins, A., Tompsett, C., Diggins, E. & Pratt, M. (2020) Voluntary uptake and continuation of treatment among court-­
involved youth: lessons learned from the implementation of Functional Family Therapy in a community setting.
Children and Youth Services Review, 105028.
Watzlawick, P., Weakland, J.H. & Fisch, R. (1974) Change: principles of problem formation and problem resolution.
London: Norton.
Weiner, D.A., Schneider, A. & Lyons, J.S. (2009) Evidence-­based treatments for trauma among culturally diverse foster
care youth: treatment retention and outcomes. Children and Youth Services Review, 31(11), 1199–­1205.
Weisman, C. & Montgomery, P. (2020) Implementation issues in functional family therapy: a narrative analysis of the
evidence. Research on Social Work Practice, 30(4), 460–­471.
White, M. & Epston, D. (1990) Narrative means to therapeutic ends. New York: Norton.
Wierzbicki, M. & Pekarik, G. (1993) A meta-­analysis of psychotherapy dropout. Professional Psychology: Research
and Practice, 24(2), 190–­195.
 |
SYSTEMIC THERAPY WITH CHILDREN AND YOUNG PEOPLE WITH
COMPLEX TRAUMA     223

Wilson, J. (2016) Engaging children and young people. In: Vetere, A. & Dowling, E. (Eds.) Narrative therapies with
children and their families: a practitioner's guide to concepts and approaches. Abingdon: Taylor & Francis, pp.
91–­112.
Yasinski, C., Hayes, A.M., Alpert, E., McCauley, T., Ready, C.B., Webb, C. et al. (2018) Treatment processes and demo-
graphic variables as predictors of dropout from trauma-­focused cognitive behavioral therapy (TF-­CBT) for youth.
Behaviour Research and Therapy, 107, 10–­18.

How to cite this article: Cobbett, S. (2022) Systemic and family therapy with socially
disadvantaged children and young people with complex trauma. Journal of Family Therapy,
44:205–­223. https://doi.org/10.1111/1467-6427.12353
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