This section provides information about complex trauma and its differences from single incident trauma. It also provides an overview of trauma-specific practice for working therapeutically with people with complex trauma experiences.
Trauma Specific Practice when working with people with Complex Trauma Experiences
Complex trauma is different to the trauma of a single incident.
Single incident trauma is associated with post-traumatic stress disorder (PTSD). Survivors of complex trauma may experience PTSD and are at increased risk of PTSD. Yet the impacts of complex trauma are more extensive and debilitating than those of PTSD alone.
People with complex trauma often develop complex post-traumatic stress disorder (C –PTSD). This is to be included in the upcoming ICD11. The new diagnosis clarifies the differences in impacts between PTSD and C-PTSD. Differences in treatment have already been recommended (Courtois & Ford, 2009; van der Kolk, 2003).
It is important to recognise that those who experience complex trauma start at a different point:
‘In contrast to the traumatised person who has experienced a sense of safety and wellbeing prior to the onset of the (single incident) trauma, the survivor of complex trauma does not start with this advantage’
What is complex trauma therapy?
`[T]here is no one perfect trauma therapy’ (Shapiro, 2010:1).
The core features of complex trauma therapy reflect clinical and neurobiological insights, including the role of the body. They have been informed by psychodynamic work (Howell and Itzkowitz, 2016), somatic (body-based) work (Rothschild, 2017; Levine, 2011; 2015; Fisher and Ogden, 2015), an understanding of trauma-based dissociation (van der Hart et al., 2016) and mindfulness and Eastern principles (Briere and Scott, 2012). Advances in technology support many previous theories. Relevant investigations include Magnetic Resonance Imaging (MRI), blood tests and Positron Emission Tomography (PET scans).
Practice based evidence also informs therapy. This considers client and therapist input into treatment effectiveness (Green & Latchford, 2012; Barkham & Hardy, 2010; Duncan, Miller et al, 2010). Common factors research is also important. It establishes that a combination of factors contributes to effective treatment. Factors include the importance of the therapeutic alliance and the relational context of therapy. Complex trauma treatment needs to be relational, regardless of the modality/ies used.
It is widely recommended that effective complex trauma therapy should be `bottom up’ and `top down’. This engages physiological and somatic (body-based) approaches, affective (emotions) and cognitive (mind) approaches (Ogden, 2006; van der Kolk, 2010; Fosha, 2003).
Complex trauma disrupts different aspects of a person, and their connections. The aim is to foster connections between these different aspects (Cozolino, 2006; Ogden, 2006; Siegel, 1999). It is also to re-integrate (reconnect) emotions, sensations, awareness and thoughts: `[i]t is important to be able to engage the relevant neurobiological processes’ (Fosha, 2003:229); `[e]ffective therapy for trauma involves the facilitation of neural integration’ (Solomon & Siegel, 2003: xviii). Body-based approaches e.g. trauma-informed yoga and mindfulness can help the body and mind reconnect.
With a practitioner:
Several key international bodies (ISSTD, 2011; ACPTMH, 2007; APA Div.56) and 84% of clinicians expert in treating complex PTSD or PTSD endorsed a phased approach to treatment (Cloitre et al., 2011).
Three phases are recommended (Cloitre et al, 2011):
- Stabilisation, resourcing and self-regulation
- Processing of traumatic memories
- Consolidation of treatment gains
The first phase (safety and stabilisation) is central and foundational. It is the focus of treatment before phases 2 and 3 (Courtois and Ford, 2013). It is important to note that these phases are not linear. Safety needs to be established time and again.
People affected by complex trauma often find it difficult to regulate their levels of arousal, emotions and behaviour. They often also find it difficult to reflect. Trying to mediate thoughts before learning to self-regulate can be re-traumatising. Studies show that people in treatment for complex trauma `may react adversely to current, standard PTSD treatments, and that effective treatment needs to focus on self-regulatory deficits rather than `processing the trauma’ (van der Kolk, 2003:173).
Most people with complex trauma have severe dissociative symptoms. Patients `with significant dissociative symptoms…respond less well to standard exposure-based psychotherapy and better to treatments that assist them with self-stabilization as well’ (Spiegel, 2018: 4).
‘On average, this treatment is longer-term than that for less complex clinical presentations. For some clients, treatment may last for decades, whether provided continuously or episodically. For others, treatment may be quite delimited, but it rarely can be meaningful if completed in less than 10-20 sessions. Even therapeutic modalities that are designed to be completed within 20-30 sessions may require more sessions or repetitions of `cycles’, or episodes, of the intervention. Obviously, goals and duration of treatment should be geared to the client’s ability, motivation, and resources. When they are limited, interventions are directed toward safety, support, education, specific skills and, in some cases, psychosocial rehabilitation and case management’ (Courtois et al, 2009:96).
Some people may need therapy on and off over their lifetime (Loewensten et al, 2014; Cloitre et al, 2011).
In a group:
Therapeutic groups can also benefit people who experience complex trauma. Such groups can foster safety and self-understanding. They can also help reduce isolation, shame and related cognitive distortions (i.e. things we believe which aren’t accurate).
Peer support can also be very important. Peers can apply an understanding of their own experiences to promote safety, build on strengths, empower recovery and build hope, optimism and support for healing. Trauma-informed peer support fosters a shared understanding of trauma experiences, coping strategies, recovery and mutual support. It fosters healing relationships, which negate the power and control of traditional services (Mead, 2008). It is important for ‘peers’ to be secure in their own recovery including knowing and managing their triggers and trauma reactions.