“Trauma is not simply an individual misfortune. It is a public health problem of major proportions.
The costs of unrecognized and untreated complex trauma are enormous. This is not only in terms of reduced quality of life, life expectancy and lost productivity, but in ‘significant increases in the utilization of medical, correctional, social and mental health services.’ In 2007 alone, the cost of child abuse to the Australian community is conservatively estimated to be at least $10.7 billion, and is almost certainly far higher.”
So begins the Executive Summary by Cathy Kezelman, the President of ASCA (Adult Survivors of Child Abuse) of its recently completed and profoundly important document ‘The Last Frontier’ Practice Guidelines for Treatment of Complex Trauma and Trauma Informed Care and Service Delivery.1 Now submitted to State (NSW) and Federal Governments, it recommends a radical revision of mental health services with a better understanding of the pervasiveness and widespread destructive consequences of complex trauma.
We can often determine the consequences of single-incident trauma by straightforward cause and effect attributions. Complex trauma is different and frequently confused with Post-Traumatic Stress Disorder (PTSD), a ubiquitous term, even if commonly misapplied.
Complex trauma is repetitive and cumulative and so has been endured on an ongoing basis. It is generated interpersonally, usually in the context of the family, primary relationships and/or perpetrated by a trusted caregiver. A betrayal of trust is a central feature which often combines with an exploitation of childhood emotional dependency. Yet, ‘complex trauma’ is not listed as a distinct syndrome in the current edition of the DSM despite its currency as a significant reference manual in Australia (despite my calling it ‘The Dumb, Stupid Manual’ in the previous edition of this journal).
PTSD is classified as an extreme anxiety disorder that is defined by the event that causes it with symptoms persisting for at least 30 days afterwards by both DSM and ICD-10. Typically, it arises from an experience that may include the threat of death, something horrific, terrifying or shocking, or perhaps also invasive.
The aftermath of complex trauma may include what we call PTSD but goes considerably beyond it and has important implications for differences in both our understanding of it, its repercussions and hence its treatment. Complex trauma has far-reaching implications for subsequent mental and emotional development, indeed even physical development.
Ongoing consequences of complex trauma into adult life involve patterns of behaviour and experience that began as normal attempts to cope with an untenable situation in the past. In the present, such patterns that began as defence mechanisms, become the problem or ‘pathology’ itself that presents for treatment whereas they originated as a solution or survival strategy.
In its simplest formulation, the effects of complex trauma permeate everything. Patients may find they are easily triggered into states of hypoarousal or hyperarousal. Self-regulation of the most basic functions of eating, sleeping, urinating, defecating, menstruating are often adversely affected. Because of this, all manner of secondaryconditions, both physical and psychological, may be brought to doctors for treatment. Sexual relations are rarely uncomplicated, if even possible. Dysregulated emotional states are typically amplified and intensified. Anxiety is pervasive, often extreme and disruptive. Flashbacks, nightmares, disturbing memories and re-experiencing of traumatic events are not uncommon. Dissociation, in different degrees and manifestations, invariably follows complex trauma. Distortions of sense perception occur. Sensorimotor issues are frequently problematic. And certainly not least, basic inter-personal relations, the experience of connectedness and a stable relational bond or attachment is fraught and typically insecure or disorganized.
Issues of the ‘self’ are standard; that is, low self-esteem, self-loathing or hatred, self-harm, self-sabotage, and extreme feelings of guilt and SHAME. The feeling of being a bad person can be almost impossible to shake. Alcohol and substance abuse are legion, often used as a form of self-medication. The clinical phenomenology of complex trauma reveals that patients often feel responsible for incurring traumatic abuse despite being children at the time, relatively helpless in the situation and often dependent upon the perpetrator, as so many of my own cases attest.
Trauma-informed Care and Treatment, whether medical, psychological, hospital-based, psychiatric, social, occupational or otherwise must understand how defining such experiences are, how persistently enduring are its consequences and how so much of subsequent development is affected. While brief interventions might have some limited value, the findings of research into the neuroscience and psychobiology of complex trauma is generating a reappraisal of psychotherapy. Informed, longer-term and in-depth therapy is required even if it is bound to be a complicated process. Collaboration between health professionals is an essential adjunct especially since medication may only play an ancillary role in mitigating symptoms.
Now, for the first time in a long time, I am feeling excited about the prospects of a renaissance for long-term, in-depth psychotherapy and what it can offer, instead of feeling demoralized by the dramatically unlevel playing field on which we operate. There is not a week that goes by without losing a client to free short-term psychology, or other practices that offer genuine Health Fund rebates. Despite that, I continue to find that people who are committed to their own recovery and development and informed health professionals who understand the value of collaboration enable my own practice to remain lively.
Despite the time and resources necessary, developments in our understanding and application of effective therapy mean that improvements in the outcomes for healing and indeed recovery from complex trauma are better than previously thought. We now understand that neural networks in the frontal cortex are stimulated by positive social experience and interaction. Specifically, the production of the neurotransmitters of serotonin, dopamine and norepinephrine are so compromised in depression and anxiety disorders that invariably follow complex trauma. Here, there is tremendous scope for psychotherapy to stimulate and repair ‘affect-regulating structures’ through positive emotional experiences so central to psychological health and the feeling of well-being.
Traditional insight-based psychotherapies are learning about the primacy of the body in treating complex trauma. This means that we do not proceed only from the top-down, moving from cognitive functioning to emotional to somatic but rather from the bottom-up, in the reverse direction.
A phased treatment approach is recommended in the ASCA document, The Last Frontier. Firstly, a feeling of safety is paramount and possibilities for stabilisation flow from there. Phase 1 involves setting the frame, boundaries and limits and rapport-building. In so many ways, we are realizing more than ever that the professional relationship isthe treatment. Secondly, processing which may represent the most substantial portion of therapy. This includes the uncovering of what happened, how that was dealt with, what the affects were, and what is still being done in the present as a consequence. Attending to dissociative tendencies, attachment patterns (often enacted in the patient’s transference to the therapist), and the manifestations of impairment to self-development characterize phase 2 processing. This leads organically to phase 3 – integration. Integration has long been held as an ultimate goal of psychotherapy. It signifies emotional development and also provides a foundation for a greater sense of self-empowerment.
Despite the linear structure, phases are intended as a guide and are not rigid or exclusive. Therapy will vary from one patient to the next. Psychotherapy has always been a process that responds to individual difference, and I remain firmly opposed to the universal application of a theory. While the adaptation to the needs of the complex trauma patient is highly individualized, the ASCA guidelines and the core principles of safety, trustworthiness, choice, collaboration and empowerment are foundational.2
These principles are most achievable when psychotherapy occurs within The Window of Tolerance.3 The idea of The Window of Tolerance comes from Pat Ogden’s Sensorimotor Psychotherapy and aims to identify a middle ground between hyperarousal and hypoarousal with a view to regulating autonomic arousal as we work with victims of complex trauma. The middle ground is where arousal is optimal, balanced and hence, most tolerable. This is also what ‘creating a safe space’ means, clinically.
Hyperarousal is expressed as increased sensation, emotional reactivity, hypervigilance, intrusive feelings, thoughts, images, fantasies or memories and disorganized cognitive processing. Hypoarousal relates to a numbing of emotions, lack of sensation, reduced physical movement and rather disabled cognitive processing, blankness, ‘spaced-out’, remote, cut-off.4
Integration also means neural integration. Convergence of findings from research on the neurobiology of attachment has demonstrated that brain plasticity is profoundly altered by early care-giving relationships in a way that is centrally-formative in the development of a sense of self. We are increasingly understanding that the way the mind, and even literally, the anatomical brain, is structured and then functions, are very largely shaped and influenced by relationships, especially the earliest emotional ones.5 Conversely, the implications for the impact of adverse experience are exponentially worse, even if the implications for healing through therapy are profound.
Over 36 years of psychotherapy practice, I have facilitated the healing and recovery of patients who have suffered so dramatically from the after-effects of complex trauma. The benefits of effective psychotherapy can be profoundly life enhancing, indeed even life saving. But it tends to take time, sometimes many, many years, for improvements to be lasting.
Now we have an evidence-base from research that combines with the practice-based evidence of the clinical experience of psychotherapists, to demonstrate such claims. It is so important for the broad-based community of medical and mental health practitioners to recognize the need for long-term psychotherapy, and to support it. Such recognition underscores effective treatment and possibilities for collaboration in patients’ best interest and moves us forward toward best practice.
I recommend checking out the ASCA website at http://www.asca.org.au/ where there is a wealth of information and you can also contact the organization to request a copy of The Last Frontier.
Concluding unscientific postscript: if readers detect a lack of my usual humour here, that is because complex trauma is, simply, no laughing matter.
- Kezelman CA, Stavropoulos PA. The Last Frontier: Practice Guidelines for Treatment of Complex Trauma and Trauma Informed Care and Service Delivery. Adults Surviving Child Abuse. 2012
- Fallot RD, Harris M (Eds.). Creating Cultures of Trauma-Informed Care (CCTIC): A Self-Assessment and Planning Protocol. Washington, DC: Community Connections; 2009. Available from: URL link
- Ogden P, Minton K, Pain C. Trauma and the Body. New York: W.W. Norton; 2006.
- Cozolino LJ. The Neuroscience of Psychotherapy: Building and Rebuilding the Human Brain. New York: Norton; 2002.
Suggestions for further reading:
1. Arnold, C & Fisch, R. The Impact of Complex Trauma on Development. Northvale, New Jersey: Jason Aronson, Inc.; 2011.
2. Briere, JN & Scott, C. Principles of Trauma Therapy – A Guide to Symptoms, Evaluation & Treatment. Thousand Oaks, California: Sage Publications; 2006.
3. Briere, JN & Lanktree, CB. Treating Complex Trauma in Adolescents and Young Adults. Thousand Oaks, California: Sage Publications; 2012.
4. Bromberg, PM. Standing in the Spaces – Essays in Clinical Process, Trauma & Dissociation. Hillsdale, New Jersey: The Analytic Press; 1998.
5. Courtois, CA & Ford, JD. (Eds) Treating Complex Traumatic Stress Disorders – An Evidence-Based Guide. New York: The Guilford Press; 2009
6. Cozolino LJ. The Neuroscience of Psychotherapy: Building and Rebuilding the Human Brain. New York: Norton; 2002. and others.
7. Davies, JM & Frawley, MG. Treating the Adult Survivor of Childhood Sexual Abuse – A Psychoanalytic Perspective. New York: BasicBooks; 1994.
8. Howell, EF. The Dissociative Mind. Hillsdale, New Jersey: The Analytic Press; 2005.
9. Kezelman CA, Stavropoulos PA. The Last Frontier: Practice Guidelines for Treatment of Complex Trauma and Trauma Informed Care and Service Delivery. Adults Surviving Child Abuse. 2012 – this document also serves as an excellent and accessible summation of current literature. You can request a copy from the ASCA website: www.asca.org.au or from me.
10. Levine, PA. Waking the Tiger: Healing Trauma: The Innate Capacity to Transform Overwhelming Experiences. Berkeley, California: North Atlantic Books; 1997. And the more recent: In an Unspoken Voice – How the Body Releases Trauma and Restores Goodness. Berkeley, California: North Atlantic Books; 2010.
11. Ogden, P, Minton, K & Pain, C. Trauma and the Body – A Sensorimotor Approach to Psychotherapy. New York: W.W. Norton & Co.; 2006.
12. McWilliams, N. Psychoanalytic Diagnosis – Understanding Personality Structure in the Clinical Process (second edition). New York: The Guilford Press; 2011. While not dealing with trauma per se this is the best text to differentiate different types of character organization. In addition, in this updated new edition, there is an important new chapter on dissociative psychologies of great relevance.
13. Rothschild, Babette. The Body Remembers: The Psychophysiology of Trauma and Trauma Treatment. New York: W.W. Norton & Co.; 2000. And many others.
14. Scaer, RC. The Trauma Spectrum – Hidden Wounds & Human Resiliency. New York: W.W. Norton & Co.; 2005. Also: The Body Bears the Burden – Trauma, Dissociation, and Disease. New York: The Haworth Medical Press; 2001.