Adult clients with a history of early, severe and continuous childhood abuse and neglect can pose many challenges for the therapist. These clients often present feeling overwhelmed and suicidal with multiple areas of difficulty in their lives, all pressing and urgent. In response therapists can feel overwhelmed by the chaos, confusion and complex problems that these clients bring.

This dissertation is a systematic literature review, illustrated with clinical vignettes, that investigates how to think about and work effectively with this client group using the lens of the trauma literature.

The first section examines how symptoms develop when children are exposed to abuse and neglect. This includes how maltreatment affects the psychological development of children and their later adult functioning.

The second section investigates the basic principles of treatment for the adult survivor of maltreatment, and argues for a stage-oriented approach to treatment with an initial focus on symptom control, self-care, and relationship issues. An extensive investigation of initial interventions is provided, because this is essential for the safety, stabilization and containment of clients. This initial stage of supportive psychotherapy is arduous, demanding and frequently overlooked by both therapist and client. Furthermore, with severely traumatized clients, this work can take months or years and some clients may never move on from this stage.

The third section reviews the therapeutic relationship. Thetransference/countertransference dynamics at the centre of this work are examined. Major role re-enactments are identified. Some of the hazards and resolutions to the impasses that these dynamics can create in the therapy with these clients are explored.

The dissertation ends with a summary of symptom development, implications for treatment and transference/countertransference issues in the treatment of severe trauma. Recommendations for psychotherapy practice and future research are examined.