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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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