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This article is written primarily
for beginning therapists and practitioners.
It provides an overview of what constitutes
complex traumatization, common initial and long-term
responses and symptoms and their diagnostic
conceptualization as complex PTSD or DESNOS
(Disorder of Extreme Stress Not Otherwise Specified).
It also provides an overview of treatment sequencing
and stages.
What is complex trauma and
what makes it different from other forms of
psychological trauma? Complex trauma
generally refers to traumatic stressors that
are interpersonal, that is, they are premeditated,
planned, and caused by other humans, such as
violating and/or exploitation of another person.
In general, interpersonal traumatization
causes more severe reaction in the victim than
does traumatization that is impersonal,
the result of a random event or an "act
of God," such as a disaster (i.e., a natural
disaster such as a hurricane or tsunami, a technological
disaster) or an accident (i.e., a motor vehicle
or other transportation accident, a building
collapse) due to its deliberate versus accidental
causation. A third type of trauma, a crossover
between the two, refers to accidents or disasters
that have a human cause (i.e., technological
disaster such as the recent Gulf oil leak or
a transportation or building accident caused
by human error, neglect, or malfeasance). Traumatic
stressors of this type have been found to cause
reactions that are more severe than those that
are impersonal and less severe than those that
are strictly interpersonal.
While interpersonal violence
can be a one-time occurrence that takes
place without warning and "out of the blue"
usually perpetrated by a stranger (i.e., a robbery,
a physical assault, a rape), when it occurs
within the family between family members or
in other closed contexts that involve significant
roles and relationships, it is usually repeated
and can become chronic over time. Child
abuse of all types (physical, sexual, emotional,
and neglect) within the family is the most common
form of chronic interpersonal victimization.
Such abuse is often founded on problematic and
insecure attachment relationships (between parent
and child or others who have primary caretaking
responsibilities). Parents and other caregivers
who abuse exploit a child's physical and emotional
immaturity and dependent status to meet their
own needs or do so in response to their own
inadequacies or distress, quite often their
own history of unresolved trauma and/or loss.
Rather than creating conditions
of protection and security within the relationship,
abuse by primary attachment figures instead
becomes the cause of great distress and creates
conditions of gross insecurity and instability
for the child including misgivings about the
trustworthiness of others. When it occurs with
a member of the family or someone else in close
proximity and in an ongoing relationship with
the child (i.e., a clergy member, a teacher,
a coach, and a therapist), it often occurs repeatedly
and, in many cases, becomes chronic and escalates
over time. The victimization might take place
on a routine basis or it might happen occasionally
or intermittently. Whatever the case, the victim
usually does not have adequate time to regain
emotional equilibrium between occurrences and
is left with the knowledge that it can happen
again at any time. This awareness, in turn,
leads to states of ongoing vigilance, anticipation,
and anxiety. Rather than having a secure and
relatively carefree childhood, abused children
are worried and hypervigilant. The psychological
energy that would normally go to learning and
development instead goes to coping and survival.
Child abuse, occurring in the
context of essential relationships, involves
significant betrayal of the responsibilities
of those relationships. In addition, it is often
private and the child is cautioned or threatened
to not disclose its occurrence. Unfortunately,
when such abuse is observed or a child does
disclose, adequate and helpful response is lacking,
resulting in another betrayal and another type
of trauma that has been labeled secondary
traumatization or institutional trauma. It
is for these additional reasons that complex
traumatization is often compounded and cumulative
and becomes a foundation on which other traumatic
experiences tragically occur over the course
of the individual's life span. Research studies
have repeatedly found that when a child is abused
early in life, especially sexually, it renders
him/her much more vulnerable to additional victimization.
Such child victims can become caught in an ongoing
cycle of violence and retraumatization over
their life course, especially if the original
abuse continues to go unacknowledged and the
aftereffects unrecognized and untreated.
Cumulative adversities faced
by many persons, communities, ethno-cultural,
religious, political, and sexual minority groups,
and societies around the globe can also constitute
forms of complex trauma. Some occur over the
life course beginning in childhood and have
some of the same developmental impacts described
above. Others, occurring later in life, are
often traumatic or potentially traumatic and
can worsen the impact of early life complex
trauma and cause the development of complex
traumatic stress reactions. These adversities
can include but are not limited to:
- Poverty and ongoing economic
challenge and lack of essentials or other
resources
- Community violence and the
inability to escape/re-locate
- Homelessness
- Disenfranchised ethno-racial,
religious, and/or sexual minority status and
repercussions
- Incarceration and residential
placement and ongoing threat and assault
- Ongoing sexual and physical
re-victimization and re-traumatization in
the family or other contexts, including prostitution
and sexual slavery
- Human rights violations
including political repression, genocide/"ethnic
cleansing," and torture
- Displacement, refugee status,
and relocation
- War and combat involvement
or exposure
- Developmental, intellectual,
physical health, mental health/psychiatric,
and age-related limitations, impairments,
and challenges
- Exposure to death, dying,
and the grotesque in emergency response work
To summarize: complex traumatic
events and experiences can be defined as stressors
that are:
(1) repetitive, prolonged,
or cumulative (2 ) most often interpersonal,
involving direct harm, exploitation, and maltreatment
including neglect/abandonment/antipathy by primary
caregivers or other ostensibly responsible adults,
and (3) often occur at developmentally vulnerable
times in the victim's life, especially in early
childhood or adolescence, but can also occur
later in life and in conditions of vulnerability
associated with disability/ disempowerment/dependency/age
/infirmity, and so on.
Such complex stressors are
often extreme due to their nature and timing:
some are actually life-threatening due to the
degree of violence, physical violation, and
deprivation involved, while most threaten the
individual's emotional mental health and physical
well-being due to the degree of personal invalidation,
disregard, deprivation, active antipathy, and
coercion involved. Many of these experiences
are chronic rather than one-time or time-limited
and they can progress in severity over time
as perpetrators become increasingly compulsive
or emboldened/entitled in their demands, as
trauma bonds develop between perpetrator and
victim/captive, and/or as their original effects
become cumulative and compounded and the victims
increasingly debilitated, despondent, or in
a state of adaptation, accommodation, and dissociation.
Because such adversities occur in the context
of relationships and are perpetrated by other
human beings, they involve interpersonal betrayal
and create difficulties with personal identity
and relationships with others.
Complex
Reactions
It is now understood that ongoing
abuse or adversity over any developmental epoch
but especially over the course of childhood
can have major impact on the individual's development
in a variety of ways and involve all life domains.
In fact, recent studies have documented that
abuse and other trauma result in changes in
the child's neurophysiological development that,
in turn, result in changes in learning patterns,
behavior, beliefs and cognitions, identity development,
self-worth, and relations with others, to name
the most common. Although some individuals who
were traumatized as children manage to escape
relatively unscathed at the time or later (often
due to personal resilience or to having had
a restorative and secure attachment relationship
with a primary caregiver that countered the
abuse effects), the majority developed a host
of aftereffects, some of which were posttraumatic
and met criteria for Posttraumatic Stress Disorder
(PTSD). But the PTSD diagnosis as currently
defined in the Diagnostic and Statistical
Manual IV-TR of the American Psychiatric
Association (American Psychiatric Association,
2000) (the mental health "Bible" that
therapists and others use to make diagnoses)
does not account for many of the aftereffects
seen in children and later in adults abused
as children, and is not, in fact, a diagnosis
for childhood PTSD. As of yet, no such diagnosis
has been included in the DSM, although a proposal
for a Developmental Trauma Disorder (DTD) has
been proposed submitted for its inclusion in
the next edition (van der Kolk, 2005).
In recognition of this omission
and the misfit encountered in applying many
of the complex trauma reactions to the criteria
of "standard" PTSD, a review of the
most common aftereffects of chronic childhood
abuse resulted in their organization into seven
criteria sets that were included in a new diagnostic
conceptualization labeled Complex PTSD or DESNOS
(Disorders of Extreme Stress Not Otherwise Specified)
(Herman, 1992 a & b). Complex PTSD was suggested
as a means of organizing and understanding the
often perplexing array of aftereffects that
had been identified into one comprehensive and
overarching diagnosis. Moreover, the diagnosis
was a way to de-stigmatize aftereffects and
symptoms by acknowledging their origin as outside
the individual and not due to the character
(or character defect) of the individual.
Unfortunately, these negative
points of view have been held by many mental
health practitioners over the years that impacted
their compassion for and treatment of traumatized
individuals. Sadly, Complex PTSD was not included
as a freestanding mental health diagnosis in
the DSM IV and was instead considered
as an associated feature form of PTSD, although
this might change in the future revisions with
additional research findings. In the meantime,
many therapists who treat children and adults
with complex trauma histories and complex trauma
reactions use this conceptualization because
it matches what they see in their clients' presentations
and helps them to explain and organize the symptoms
and to further organize their treatment. In
fact, Complex PTSD/DESNOS was immediately accepted
and used by a wide variety of clinicians treating
patients with complex trauma histories because
it had face validity in that it matched the
varied presentations made by their clients and
was a more parsimonious and less stigmatizing
way to understand and diagnose the symptom constellation
they presented.
The "traditional"
or "classical standard" criteria that
make up the original diagnosis of PTSD in the
DSM III-TR (American Psychiatric Association,
1980) were derived from the study of war trauma
and adult soldiers and included: (1) intrusive
re-experiencing of traumatic memories, (2) emotional
numbing and avoidance of reminders of the trauma,
including memory loss, and (3) hyperarousal,
in addition to various associated features such
as depression and anxiety and other co-morbidities.
Complex traumatic stress disorders routinely
include a combination of additional DSM-IV
TR Axis I and Axis II (developmental/personality)
disorders and symptoms, Axis III physical health
problems, and severe Axis IV psychosocial impairments.
Due to the complex traumatic antecedents (in
the distant past as well as in the present)
and the resultant array of traumatic stress
symptoms and other impairments, complex traumatic
stress disorders tend to be difficult to diagnose
accurately and treat effectively. It would be
useful to have a diagnostic conceptualization
that is encompassing to understand and organize
the various aftereffects.
The seven categories of additional
aftereffects include the following:
1. Alterations in the regulation
of affective impulses, including difficulty
with modulation of anger and of tendencies towards
self-destructiveness. This category has come
to include all methods used for emotional regulation
and self-soothing, even those that are paradoxical
such as addictions and self-harming behaviors;
2. Alterations in attention
and consciousness leading to amnesias and
dissociative episodes and depersonalization.
This category includes emphasis on dissociative
responses different than those found in the
DSM criteria for PTSD. Its inclusion in the
CPTSD conceptualization incorporates findings
that dissociation tends to be related to prolonged
and severe interpersonal abuse occurring during
childhood and, secondarily, that children are
more prone to dissociation than are adults;
3. Alterations in self
perception, predominantly negative and
involving a chronic sense of guilt and responsibility,
and ongoing feelings of intense shame. Chronically
abused individuals (especially children) incorporate
abuse messages and posttraumatic responses into
their developing sense of self and self-worth;
4. Alterations in perception
of the perpetrator, including incorporation
of his or her belief system. This criterion
addresses the complex relational attachment
systems that ensue following repetitive and
premeditated abuse and lack of appropriate response
at the hands of primary caretakers or others
in positions of responsibility;
5. Alterations in relationship
to others, such as not being able to trust
the motives of others and not being able to
feel intimate with them. Another "lesson
of abuse" internalized by victim/ survivors
is that other people are venal and self-serving,
out to get what they can by whatever means including
using/abusing others. Abuse survivors may be
unaware that other people can be benign, caregiving,
and not dangerous;
6. Somatization and/or
medical problems. These somatic reactions
and medical conditions may relate directly to
the type of abuse suffered and any physical
damage that was caused or they may be more diffuse.
They have been found to involve all major body
systems and to include many pain syndromes,
medical illnesses and somatic conditions;
7. Alterations in systems
of meaning. Chronically abused and traumatized
individuals often feel hopeless about finding
anyone to understand them or their suffering.
They despair of being able to recover from their
psychic anguish.
Research has shown that individuals
who have symptoms that meet criteria for the
complex trauma diagnosis may or may not have
the additional symptoms associated with standard
forms of PTSD (Ford & Kidd, , 1998); that
is, they may have all of the complex trauma
criteria but may or may not have PTSD symptoms,
per se.
Of note, many of the major
characteristics resemble the symptom picture
of emotional lability, relational instability,
impulsivity, unstable self-structure sense of
self, and self-harm tendencies most associated
with borderline personality disorder (BPD; American
Psychiatric Association, 1994). The BPD diagnosis
has carried enormous stigma in the treatment
community where it continues to be applied predominantly
to women clients in a pejorative way, usually
signifying that they are irrational and beyond
help. In recent years, this diagnosis that has
come to be understood as a posttraumatic adaptation
to recurrent and severe childhood abuse, attachment
trauma, and personal invalidation, giving therapists
another way to understand and treat it. We conceptualizing
and understanding BPD from a complex trauma
perspective can assist the clinician in being
more empathic towards the client and more even-handed
in terms of treatment and personal reactions
(countertransference and vicarious trauma).
Complex
Treatment
Despite these shifts in orientation
understanding the aftereffects and their origins,
the individuals with CPTSD/DESNOS (or BPD) diagnosis
can be a difficult population to treat. Psychotherapy
is fraught with many complications (Chu, 1992;
Linehan, 1993) due to the number of issues symptoms
the client might experience, issues with personal
safety, and deficiencies in the ability to regulate
affect and to apply other life skills.; Exposing
these patients clients too directly to their
trauma history in the absence of their ability
to maintain safety in their lives or to self-regulate
strong emotions can lead to retraumatization,
and associated decompensation, and inability
to function.
In recent years, treatment
for patients with the "classic" form
of PTSD has increasingly emphasized the use
of cognitive-behavioral interventions (CBT),
including prolonged exposure (PE) and cognitive
restructuring (CR), techniques for which empirical
research support has become available (Foa,
Friedman, Keane, Friedman, & Cohen, 2008).
The research substantiation of the effectiveness
of these techniques in ameliorating the often
refractory symptoms of PTSD is laudable. Unfortunately,
the wholesale application use of CBT exposure
techniques to in patients with CPTSD/DESNOS
(even those who clearly have PTSD symptoms)
may be problematic if applied too early in treatment
and before the client is stable and safe.
CPTSD/DESNOS (even those who
clearly meet criteria for PTSD) may be problematic
and resurface some of the problems described
in the previous paragraph. In response to this,
the recommended course of treatment from those
experienced in treating CPTSD (Chu, 1998; Courtois,
1999, 2004; Courtois, Ford, & Cloitre, 2009;
Ford, Courtois, Van der Hart, Nijenhuis, &
Steele, 2005) involves the sequencing of
healing tasks across several main stages of
treatment. These stages include (1) pre-treatment
assessment, (2) early stage of safety, education,
stabilization, skill-building, and development
of the treatment alliance, (3) middle stage
of trauma processing and resolution, and (4)
late stage of self and relational development
and life choice There is overlapping therapeutic
work throughout the stages and often a need
to rework stabilization skills over the course
of treatment. But as each stage builds on the
previous work, the trauma survivor acquires
growing control and mastery, which directly
counteract the powerlessness of victimization
and its continuing aftereffects.
The pre-treatment assessment
should be comprehensive, with attention to diagnosis
within the posttraumatic/dissociative spectrum,
posttraumatic and other symptoms, safety, and
comorbidity (particularly substance abuse, medical
illness, eating disorders, and affective disorders).
It is useful to complete all five axes of the
DSM, with emphasis on current stressors
and available resources for use in the development
of a treatment plan. This is also the time to
take a broad look at needs and resources, including
available health care resources, which can so
easily be limited by a client's disability or
by managed care insurance coverage or by his/her
own motivation or emotional capacity for treatment.
The early stage focuses
on safety, stabilization, and establishing the
treatment frame and the therapeutic alliance.
Measured by mastery of the necessary skills
and not by duration, this stage of treatment
may be the most important since it is directly
related to the clients' capacity to function.
Education in complex trauma and elements of
the human response to trauma provide a foundation
for skill-building. Skills to be developed include
healthy boundaries, safety planning, assertiveness,
self-nurturing and self-soothing, emotional
modulation, and strategies to contain trauma
symptoms such as spontaneous flashbacks and
dissociative episodes. Additionally, attention
to wellness, stress management and any medical/
somatic concerns is needed. Medications such
as antidepressants and anti-anxiety drugs are
often helpful and should be considered to target
posttraumatic symptoms and those associated
with depression, anxiety, and sleep disorders.
The middle stage of treatment
begins only after stabilization skills have
been developed and are utilized as needed. This
stage involves revisiting and reworking the
trauma with careful processing to integrate
traumatic material along with its associated
but often avoided emotion. This stage typically
involves the expression of pain and profound
grief but with the support and witnessing of
the therapist. The re-working of trauma is always
destabilizing, so the skills learned in the
early stage of treatment provide the frame and
skill-set needed to face and integrate the previously
avoided traumatic material. A wide variety of
techniques have been developed for processing
trauma that are applicable to this treatment
stage including prolonged or graduated exposure,
cognitive processing therapy, cognitive restructuring,
narrative exposure, and reprocessing, testimony,
and Eye Movement Desensitization and Reprocessing,
to name the most common.
The late stage of treatment
involves identity and self-esteem development
and concurrent development of improved relational
skills and relationships. The important issues
of intimacy, sexuality, and current life choices,
including whether to continue certain relationships
and vocational choices typically occurs in this
stage, if they have not been addressed earlier.
Additionally, clients at this stage often encounter
an existential crisis associated with a new
sense of self and must struggle with the meaning
of the now integrated trauma memories and with
the losses they have endured. Survivors at this
stage often struggle to embrace life with renewed
energy and hope for the future. For some, meaning-making
may involve a commitment to make a difference
in the world, particularly with respect to decreasing
violence. This is sometimes referred to as a
"survivor mission."
The course of treatment and
its duration can vary quite dramatically and
a variety of different treatment strategies
might be used across the stages of treatment.
Some clients stay in therapy for years (especially
those with the most extensive trauma histories
and those with insecure attachment styles) may
never move beyond the first stage, while others
move through the three stages in much less time,
and still others only engage in treatment episodically
as needed. Shorter-term and "hybrid"
approaches (Cloitre, Cohen, & Koenen, 2006;
Ford & Russo, 2006; Gold, 2000) are now
under development. The important consideration
is that new and different approaches to the
treatment of complex trauma are now available
and effective. Survivors who were once confused
by their symptoms and who despaired of ever
receiving understanding and assistance now have
the opportunity to receive effective treatment,
to heal, and to get their lives back and on
track.
Christine A Courtois,
PhD & Associates, PLC is a private
practice that specializes in the treatment of
adults experiencing the effects of childhood
incest/sexual abuse and other types of trauma.
Dr. Courtois has worked with these issues for
30 years and has developed treatment approaches
for complex posttraumatic and dissociative conditions
for which she has received international recognition.
www.drchriscourtois.com
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