From: Complex trauma and its effects: perspectives on creating an environment for recovery
© Robin Johnson
Published by: Pavilion Publishing (Brighton) Ltd
First edition published 2012
……….
The Drama Triangle and other ‘unwanted repetitive patterns’
An interview with Susan King. TA therapist and clinical lead in Nottinghamshire Mental Health Foundation
Trust’s Learning Difficulties service
RJ: One of the issues we are exploring is the extent to which early trauma may become, to all intents
and purposes, ‘hard-wired’ into the developing infant brain; or whether it is perhaps more accurate
and helpful to think more dynamically and to consider, for example, the seriously dysfunctional
behaviour and relationships that we see in people with personality disorders as the product of a long
sequence of on-going interactions and mismanagements.
So it would be useful to make some comparison with the management of problematic behaviour in
Learning Disability services. In LD, as I see it, there is good reason to believe that the underlying
damage – if that is the right word? - is indeed early, irreversible, and purely physiological. Yet the
difficulties in living that people with LD do have, they have in the present, and the problematic
interaction issues are on-going. The contrast may therefore help to highlight the role of other people’s
responses in helping or hindering recovery.
SK: In LD there will be some underlying irreversible damage. However, people with LD do have
personalities, and some people with LD will have PD too. Many others have attachment difficulties,
falling short of formally diagnosed or diagnosable PD. LD on its own rarely causes major behavioural
difficulties except in severe and profound LD. Indeed the incidence of abuse of children with
disabilities is far higher than in children without, so trauma is very often a component of the problems
we see in people with learning disabilities.
Much of our work in LD is therefore to help discern what is changeable and what is unchangeable and
how best to respond to both. Much of this is done with staff teams and family carers, and more rarely
with ward staff, but often with supported living projects or residential homes. At its simplest, the staff
and those agencies are being commissioned to manage these things well and so this is where we
should focus our efforts on helping them to learn to do things better.
Staff training and support
RJ: Let’s look at the question of staff training, because that is certainly one of the areas where the
interface between the individual and the agency is most open to change. Training is the most obvious
opportunity to introduce new ideas and to question how things are happening, and certainly training
can aim to support or generate reflective practice, which is a huge part of making changes in cultures.
SK: We also have to ask what exactly we think training is. Unfortunately, the call for more training
often seems to reduce itself to treating staff as blank slates on which new skills have to be inscribed.
We also have to consider how far poor practice, or un-reflective services, are really just a matter of
the individual staff members’ lack of skills, or to what extent it may also be embedded in the culture
of the team –what we believe we are here to do; or whether it is equally in the role adopted by the
agency. The terms of the contract and the commissioners who fund or purchase these services may
also be stuck in narrow patterns of ideas about services and practices that they feel they can’t
question.
Far too often what you find in 'training' is that staff members are sat down in front of a screen with a
series of PowerPoint slides and bullet points and fed information. It is slightly more interactive than
reciting the mission statement, but it can be equally disconnected from real life and real learning.
Sometimes they are trained in skills such as how to give people choices, or how to engage them in
activities, but it is particularly important to realise that staff are not virgin territory and their minds
were not blank slates before the trainer walked in the room.
Most people come to care work with some kind of folk psychology, implicit ideas of their own that
they have been brought up with and live their lives with. These ideas are generally not elaborated, and
rarely put into words, but they affect how staff view the behaviour of those they support, and how
they feel they should respond. So 'training' may be a misnomer for the process that needs to occur. It
needs to be much more of a co-construction of useful models and tools to understand and develop the
work, and it needs to take place in a context and a culture of ongoing reflective practice, supported by
supervision etc.
For example, one prevailing model we often need to address, expressed in a statement that we hear a
lot, is that 'there have to be consequences'. In other words, although it is not generally phrased so
starkly, if there is bad behaviour, there must be punishment. This is a strong belief system; all the
stronger for being unexamined and unelaborated. I sometimes describe it as poor behaviourism, in
that it goes against all the evidence of what works for managing behaviour even within a behaviourist
model.
It is rooted as much in a folk morality as in any folk psychology. There is a sense that if people are
allowed to 'get away with bad behaviour', a fundamental injustice is done. Of course this is no more
thought through philosophically than it is psychologically, but it needs to be addressed often both in
terms of 'teaching proper behaviourism', from the psychological angle, and opening up a philosophical
or ethical discussion too.
Changing staff's psychological model
RJ: And this doesn’t work?
SK: Psychologically, thinking that unwanted behaviour should be managed by consequences simply
does not take into account the needs of many people with LD. Their LD may mean they will have
difficulty learning from consequences. With some people, their disability is so severe that they really
cannot learn new behaviour; in others, it would simply take a very long time. For some, however,
their behaviour is driven by its antecedents, its triggers, rather than by consequences, so the behaviour
will only be changed if the antecedents are changed. To respond to challenging behaviour with
‘consequences’ in those situations is naïve, verging on cruel.
Changing the antecedents generally means changing the environment: the physical environment,
and/or the social environment. You might ensure the environment is less noisy and overstimulating, or
that it is more responsive, or more predictable etc.
Even where people can learn from consequences and their behaviour is consequence driven, we may
need to teach staff that to use behaviourism properly, you need to ensure clients get positive
consequences for their positive behaviour, especially as the evidence suggests that the lower the
person's IQ or developmental age, the more likely it is that they will learn more from positive than
negative consequences.
RJ: Could you say a little more about adjusting the environment?
SK: A concept used at times in LD services (and in services for people with brain injury and
dementia) is that of the 'prosthetic environment'. A prosthetic environment is one that compensates for
the person’s impairments, in the same way that a prosthetic arm makes up for a lost arm. For example,
making it impossible to look out of the window by drawing the blinds in a classroom to compensate
for the attentional difficulties of a pupil with ADHD (Attention Deficit Hyperactivity Disorder) is to
create a prosthetic environment. To ensure staff plan and manage the budget of people who do not
have the cognitive ability to manage their money is to create a prosthetic environment. To give a
person with extensive memory deficits electronic memory aids is to create a prosthetic environment.
A prosthetic environment is often distinguished from a therapeutic environment, which would be an
environment that is designed to teach new skills, behaviours and ways of being. However a prosthetic
environment may change someone’s behaviour by providing them with a sense of security so that
they do not need to act out of fear and anxiety. You might argue that both prosthetic and therapeutic
environments are enabling.
RJ: It certainly fits well within that broader concept of an ‘enabling environment’ that we have been
aiming to promote. Can we return then to the question of staff training, and reflective practice?
Changing staff's ethical model
SK: You may teach a wider understanding of behaviour management, but this will not address staff's
view of justice, and how their interaction with clients can demonstrate justice. Getting people to
reflect on folk morality isn’t easy though. One reason it is so hard is that it is not just at work, it may
be how they run their whole lives. If you are saying it might not always be true and right that people
have to be punished with consistent consequences, it can mess with staff's heads in so many ways.
That person then goes home and they have to think differently about things there too. That’s a lot to
ask.
If you are looking at the training of staff, and indeed a wider process of supporting their reflective
practice, perhaps the most useful thing is to bring into the room the ideas they already have about
learning, or justice, or sympathy, or needs. Sometimes just saying, 'This is the world view I was
brought up with' is a good place to start. That then allows people to step back and hopefully say, 'OK,
this is what I believe, but when I am at work here, I may have to consider how different things need to
be here'. Rather than simply trying to hammer new ideas on top of old ones, it may be a lot more
promising to suggest that we look at how many models of human behaviour we have in the room, and
then encourage them talk to each other. That is a lot more engaging than thinking that people don’t
have any model in their heads and that they are virgin territory so we can instil a model in them.
Learning to deal with the emotional impact of the work
RJ: We would need to recognise that exposing your own fundamental beliefs to others, even
to close colleagues, might feel rather intimidating.
SK: A very important dimension that is often missed is that working with traumatised people is
distressing. Yet it is very rare that work is undertaken with staff to address the emotional impact of
the work they do, and how to manage that, or the quality of relationships they make with the people
they support, and how to enhance that. Indeed, organisationally the quality of relationship may be
poor all the way up the tree. Yet without that, any other training or reflection is of little use.
Generally in learning disability services in this country most of the training focus is on the skills
needed to 'promote independence'. Yet we need to recognise that the emotion of the client affects the
staff and that the staff need to manage this, and that there are specific, usually unnamed and implicit
rather than explicit and taught, skills that staff use every day to do this.
Professor Carlo Schuengel and his team at the Free University of Amsterdam have an extensive
research programme on attachment in learning disability services. Insecure attachment patterns are
common in people with learning disabilities, and correlate closely with challenging behaviour.
Professor Schuengel and his team have developed a range of programmes to coach staff in the skills
of sensitive responsiveness, which they demonstrate can enable the creation of a secure base, and
facilitate the learning of new, more adaptive behaviours.
The drama triangle: one way of understanding unwanted repetitive
roles in care services
RJ: Then could we perhaps move onto the notion of the Drama Triangle. It is one example of a
straightforward model of the knots people can get into with each other, that can help staff to reflect on
their practice, and I believe it was you yourself that first introduced me to this.
SK: Karpman's Drama Triangle comes from the quite early days of Transactional Analysis (TA), a
way of describing the process also known as psychological games. I find the Drama Triangle useful as
a way of simply explaining unhelpful repetitive patterns to staff teams, however it is one of many
models of such processes. Others include Cognitive Analytic Therapy’s (CAT) idea of Reciprocal
Roles, Karl Tomm's ideas of Pathologising Interpersonal Patterns versus Healing Interpersonal
Patterns; or Barnett Pearce’s idea of Unwanted Repetitive Patterns, in which participants feel that they
have no choice but to act in particular way in a particular context.
However, your interest is in the Drama Triangle so let's explain it here. A 'game' in Transactional
Analysis is a series of transactions that is complementary (reciprocal), has an ulterior motive or payoff, and proceeds towards a predictable outcome. One of the key features of such games is that they
are characterised by a switch in roles of players towards the end. The Drama Triangle posits three
typical, even habitual positions, which people find themselves taking up in such a game. There is:
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the person who is treated as, or accepts the role of, a victim
the person who pressures, coerces or persecutes the victim
the person who rescues, ie. intervenes out of an ostensible wish to help the victim.
In the Drama Triangle, the drama plays out as follows:
'[A protaganist] start[s] off in one of the three main roles: Rescuer, Persecutor, or Victim, with the
other principal player (the antagonist) in one of the other roles. The Victim is not really as helpless as
he feels, the Rescuer is not really helping, and the Persecutor does not really have a valid complaint.
Thereafter the two players move around the triangle, thus switching roles.' (Berne, 1975)
The idea is that, for example, the Victim turns on the Rescuer, or the Rescuer switches to
Persecuting.
Note that the 'game' position of Rescuer is distinct from that of a genuine rescuer in an emergency,
such as a firefighter or a lifeguard. When played as a drama role, there is something unspoken about
the Rescuer's attempts, a mixed motive or need to be a rescuer or to have a victim to help. In fact, 'The
Karpman Triangle game inhibits real problem-solving ... [and] creates confusion and distress, not
solutions'.
The triangle in care services
The Drama Triangle positions of Victim, Persecutor and Rescuer make particular sense in the care
professions, which makes it a useful model to teach to social workers, nurses, doctors, care staff,
support workers and so on. The switch – which is so characteristic of games - plays out in the care
professions too, for example, when the Rescuer is so exhausted by their endlessly fruitless attempts to
make things better that they may start to behave in ways that seem resentful and punitive towards the
others. So they themselves may perceive themselves as the Victim and then behave as Persecutor to
the others. 'Look how hard I am working with no gratitude,’ they might say, ‘at least you might
appreciate it and not make it too hard - why aren't you getting better?’ Alternatively, the Victim may
harry and denigrate anyone who steps out of the Rescuer role, or who does not help them in the right
way. The Persecutor may then switch to Rescuing one of the other parties who has moved to the
Victim position.
For most of us, a dawning recognition of the Drama Triangle game’s dynamic in play will often start
with a question such as, 'How on earth did we get into this again?' That is when just knowing the
concept of the Drama Triangle can help us then step back and say, 'Hold on – maybe that’s what’s
going on here'.
If any one individual can then step out of the 'inevitable' sequence, it creates some emotional space,
perhaps, for the others to do something different too. In TA and likewise in CAT, the solution is to
resist the pull to move into the role that is evoked by the behaviour of the other, and, through
reflecting on your own behaviour, to adopt a more neutral, grown-up stance.
The winners’ triangle
When the Drama Triangle was first proposed, the main conclusion was that workers and others should
avoid being pulled into the drama – ‘don’t just do something, stand there’. However, others working
in the same TA mode have since suggested more positive responses. In the Winner’s Triangle (Choy,
1984), for example, each of the roles of the original Drama Triangle have their equivalent role in a
comparable triangular relationship, but the roles of each take a more constructive stance.
Here, the Rescuer now adopts the position of caring, and listening; the Persecutor aims to be assertive,
without blaming; and the Victim acknowledges that they are vulnerable, and are focused on problemsolving. Whichever player it may be that first attempts to break out of the role in which they have
been cast by others – or which, they tend themselves to adopt – also aims to use the same
reciprocating dynamic to then elicit the matching more positive response from the others in the
triangle.
The strategy offered is therefore to take, and seek, the appropriate aspects of each position’s emotions,
and bring out what is legitimate without over-balancing into blaming others. It is, again, about true
assertiveness and self-expression, returned to a more ‘mature’ or adult position. (In the original
terminology of TA, they each say, ‘I’m OK, you’re OK’.)