Complex Trauma
Complex trauma, or Complex Post-Traumatic Stress Disorder (CPTSD), is a form of repetitive, interpersonal trauma that often occurs during childhood, such as sexual abuse or domestic violence (Courtois, 2008). In 2015, 9.2 out of every 1000 children were reported as victims of neglect (U.S. Department of Health & Human Services, 2017). As these children develop into adulthood, evidence of complex trauma may appear in the form of cognitive and behavioral impairments, as well as various mood and personality disorders (Olson-Morrison, 2017). Treatment is often focused on the disorders rather than the actual trauma itself. Courtois (2008) outlines seven areas of impairment which serve as diagnostic criteria for complex trauma. She argues that cultivating
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safety is the primary concern and provides three stages of treatment as guidelines to addressing these deficits. Expressive therapies, also called creative therapies, facilitate healing through self-expression, active participation, imagination, and the mind-body connection through media such as art, poetry, drama, and music (Malchiodi, 2005). Rowe (2017) claims that art therapy may be a beneficial alternative to traditional cognitive-behavioral therapies, following the concept that trauma is held in the memory as images, which are most effectively processed through art-based interventions and may be less direct. Utilizing Courtois’ (2008) diagnostic criteria, we select three aspects upon which to focus expressive therapy interventions.
Complex trauma involves either violation by or failure of protection from the individuals that are typically charged with the child’s safety (Courtois, 2008). Due to the vulnerability of the victim, such ongoing violations are often accompanied by a feeling of entrapment. Ongoing war or combative situations, refugee populations, and illnesses that require several invasive medical procedures may also result in complex trauma. Developmental trauma resembles CPTSD in that it occurs as children are exposed to interpersonal trauma (Olson-Morrison, 2017). However, as these repetitive incidences continue to transpire through a cycle of trauma, reaction, and adaptation, layers of complexity are added that manifest themselves in adulthood in various ways. Tarocchi, Aschieri, Fantini, and Smith, (2013) claim that as the types of events increase, the number of disorders increase, as well. Unfortunately, the prevalence of neglect in the U.S. is not uncommon.
In a recent report of childhood maltreatment, the U.S.
Department of Health and Human Services (2017) found that in 2015 over 683,000 children were found to be victims of some form of abuse. Of those children, 75.3% experienced neglect, 17.2% experienced physical abuse, and 8.4% were sexually abused with some of children experiencing polyvictimization. Children of caregivers that abused drugs or alcohol, or that were inflicted by domestic violence were at a higher risk for maltreatment. It has been found that four or more adverse experiences during childhood greatly increases the likelihood of disorders such as anxiety, major depression, substance use, and antisocial behavior into adulthood (Tarocchi et al., 2013). Courtois (2008) highlights the characteristics encountered as these children reach …show more content…
adulthood.
Adults that have a childhood history of complex trauma are observed to have difficulty in various aspects of their lives (Courtois, 2008). These individuals also tend to engage in high-risk behaviors, such as suicidality and substance use. Specific symptoms can include hyperarousal, avoidance, distorted cognition, intrusive experiences, as well as difficulty in the areas of emotion-regulation, avoiding revictimization, and maintaining intimate relationships.
Due to the complexity of the trauma history and symptomology, issues in treatment may be challenging to overcome (Courtois, 2008). Treatment tends to focus on symptoms and disorders rather than the underlying trauma, which neglects the neurobiological and developmental deficits (Olson-Morrison, D. 2017). Due to this unintentional overlook, it is pertinent that a thorough assessment is performed initially and as the therapeutic relationship evolves (Courtois, 2008).
Assessment
Often clients seek therapy for associated disorders or to correct maladaptive behavior, but because complex trauma has features of a brain injury its treatment should take precedent over the maladaptive behavior (Olson-Morrison, 2017). The aforementioned symptoms, as well as types of dissociation, boundary issues, distorted sense of self, and trauma exposure should be evaluated. (Tarocchi et al., 2013).
An extensive assessment is necessary as it provides information regarding symptoms, sense of self, ability to regulate emotion, and relational ability, which create a useful starting point for therapy (Courtois, C. 2008). Standard instruments will likely not detect Post-Traumatic Stress Disorder (PTSD) symptoms and so they should be supplemented by those that do with reliability and validity. Both self-report measures (e.g., MMPI-2) and performance-based tests (e.g., Rorschach) are useful in obtaining a comprehensive picture of the client’s symptoms (Tarocchi, 2013).
A variety of instruments specific to trauma also exist including the Trauma Symptom Inventory (TSI) that evaluates self-identity and interpersonal relationships, and the Structured Interview for Disorders of Extreme Stress (SIDES), which are both helpful in identifying CPTSD symptoms (Courtois, 2008). The Inventory of Altered Self Capacities (IASC), Cognitive Distortion Scales (CDS), and Trauma and Attachment Belief Scale are among the other instruments that may be used.
When screening for dissociation, the Dissociative Experiences Scale (DES) is useful, but requires supplemental tests for more detailed information (Courtois, 2008). The Multiscale Dissociation Inventory (MDI) and Somatoform Dissociation Scale (SDQ-20) are sufficient supplements, as well. Courtois (2008) provides some guidelines for administering the assessment.
Due to the sensitivity of trauma, it is favorable to integrate questions casually during the initial intake and continue to check-in throughout the relationship, as the client may not disclose important information until they feel they can trust the therapist (Courtois, 2008). Keep in mind that both hearing the question as well as responding honestly can be painful for the client; therefore, openness and neutrality are important characteristics when approaching this task. Be mindful of the client during and after the session, watching for revelation of symptoms that were previously unseen. Demonstrate concern and priority for client’s safety over their disclosure. As some symptoms are subtle, it is beneficial for therapists to seek specialized training to identify them. It is important to empower the client, encouraging growth, identity, and a secure attachment to the therapist by identifying and being supportive of their strengths rather than placing a high emphasis on the traumatic event. Attend to the whole person rather than the incidences that led to the trauma.
It should be noted that forms of evaluation may be achieved through the expressive therapies to collect helpful information (Malchiodi, 2005); however, these should be utilized as supplements to the specialized instruments mentioned. In distinguishing complex trauma, there are seven proposed criteria that are examined (Courtois, 2008).
Diagnostic Criteria
Based on findings by Judith Herman, Courtois (2008) reiterated the following seven areas associated with complex trauma:
1. Alterations in the regulation of affective impulses.
2. Alterations in attention and consciousness.
3. Alterations in self-perception.
4. Alterations in perception of the perpetrator.
5. Alterations in relationship to others.
6. Somatization and/or medical problems.
7. Alterations in systems of meaning (p. 88).
These aftereffects of complex trauma add a layer of complexity to the treatment, creating additional challenges that are not present in classic PTSD patients, as trust and secure attachment are critical for establishing a safe environment (Tarocchi et al., 2013).
While exposure therapy is a common treatment for PTSD patients, one issue in working with individuals who endorse complex trauma is that they may face retraumitization if they have not first established and learned how to preserve feelings of safety. Following assessment, Courtois (2008) argues that the sequencing of the treatment is important and should be especially cautious in the beginning while the foundations of safety and emotion regulation are being established. She presents a three-stage model that should be
employed.
safety is the primary concern and provides three stages of treatment as guidelines to addressing these deficits. Expressive therapies, also called creative therapies, facilitate healing through self-expression, active participation, imagination, and the mind-body connection through media such as art, poetry, drama, and music (Malchiodi, 2005). Rowe (2017) claims that art therapy may be a beneficial alternative to traditional cognitive-behavioral therapies, following the concept that trauma is held in the memory as images, which are most effectively processed through art-based interventions and may be less direct. Utilizing Courtois’ (2008) diagnostic criteria, we select three aspects upon which to focus expressive therapy interventions.
Complex trauma involves either violation by or failure of protection from the individuals that are typically charged with the child’s safety (Courtois, 2008). Due to the vulnerability of the victim, such ongoing violations are often accompanied by a feeling of entrapment. Ongoing war or combative situations, refugee populations, and illnesses that require several invasive medical procedures may also result in complex trauma. Developmental trauma resembles CPTSD in that it occurs as children are exposed to interpersonal trauma (Olson-Morrison, 2017). However, as these repetitive incidences continue to transpire through a cycle of trauma, reaction, and adaptation, layers of complexity are added that manifest themselves in adulthood in various ways. Tarocchi, Aschieri, Fantini, and Smith, (2013) claim that as the types of events increase, the number of disorders increase, as well. Unfortunately, the prevalence of neglect in the U.S. is not uncommon.
In a recent report of childhood maltreatment, the U.S.
Department of Health and Human Services (2017) found that in 2015 over 683,000 children were found to be victims of some form of abuse. Of those children, 75.3% experienced neglect, 17.2% experienced physical abuse, and 8.4% were sexually abused with some of children experiencing polyvictimization. Children of caregivers that abused drugs or alcohol, or that were inflicted by domestic violence were at a higher risk for maltreatment. It has been found that four or more adverse experiences during childhood greatly increases the likelihood of disorders such as anxiety, major depression, substance use, and antisocial behavior into adulthood (Tarocchi et al., 2013). Courtois (2008) highlights the characteristics encountered as these children reach …show more content…
adulthood.
Adults that have a childhood history of complex trauma are observed to have difficulty in various aspects of their lives (Courtois, 2008). These individuals also tend to engage in high-risk behaviors, such as suicidality and substance use. Specific symptoms can include hyperarousal, avoidance, distorted cognition, intrusive experiences, as well as difficulty in the areas of emotion-regulation, avoiding revictimization, and maintaining intimate relationships.
Due to the complexity of the trauma history and symptomology, issues in treatment may be challenging to overcome (Courtois, 2008). Treatment tends to focus on symptoms and disorders rather than the underlying trauma, which neglects the neurobiological and developmental deficits (Olson-Morrison, D. 2017). Due to this unintentional overlook, it is pertinent that a thorough assessment is performed initially and as the therapeutic relationship evolves (Courtois, 2008).
Assessment
Often clients seek therapy for associated disorders or to correct maladaptive behavior, but because complex trauma has features of a brain injury its treatment should take precedent over the maladaptive behavior (Olson-Morrison, 2017). The aforementioned symptoms, as well as types of dissociation, boundary issues, distorted sense of self, and trauma exposure should be evaluated. (Tarocchi et al., 2013).
An extensive assessment is necessary as it provides information regarding symptoms, sense of self, ability to regulate emotion, and relational ability, which create a useful starting point for therapy (Courtois, C. 2008). Standard instruments will likely not detect Post-Traumatic Stress Disorder (PTSD) symptoms and so they should be supplemented by those that do with reliability and validity. Both self-report measures (e.g., MMPI-2) and performance-based tests (e.g., Rorschach) are useful in obtaining a comprehensive picture of the client’s symptoms (Tarocchi, 2013).
A variety of instruments specific to trauma also exist including the Trauma Symptom Inventory (TSI) that evaluates self-identity and interpersonal relationships, and the Structured Interview for Disorders of Extreme Stress (SIDES), which are both helpful in identifying CPTSD symptoms (Courtois, 2008). The Inventory of Altered Self Capacities (IASC), Cognitive Distortion Scales (CDS), and Trauma and Attachment Belief Scale are among the other instruments that may be used.
When screening for dissociation, the Dissociative Experiences Scale (DES) is useful, but requires supplemental tests for more detailed information (Courtois, 2008). The Multiscale Dissociation Inventory (MDI) and Somatoform Dissociation Scale (SDQ-20) are sufficient supplements, as well. Courtois (2008) provides some guidelines for administering the assessment.
Due to the sensitivity of trauma, it is favorable to integrate questions casually during the initial intake and continue to check-in throughout the relationship, as the client may not disclose important information until they feel they can trust the therapist (Courtois, 2008). Keep in mind that both hearing the question as well as responding honestly can be painful for the client; therefore, openness and neutrality are important characteristics when approaching this task. Be mindful of the client during and after the session, watching for revelation of symptoms that were previously unseen. Demonstrate concern and priority for client’s safety over their disclosure. As some symptoms are subtle, it is beneficial for therapists to seek specialized training to identify them. It is important to empower the client, encouraging growth, identity, and a secure attachment to the therapist by identifying and being supportive of their strengths rather than placing a high emphasis on the traumatic event. Attend to the whole person rather than the incidences that led to the trauma.
It should be noted that forms of evaluation may be achieved through the expressive therapies to collect helpful information (Malchiodi, 2005); however, these should be utilized as supplements to the specialized instruments mentioned. In distinguishing complex trauma, there are seven proposed criteria that are examined (Courtois, 2008).
Diagnostic Criteria
Based on findings by Judith Herman, Courtois (2008) reiterated the following seven areas associated with complex trauma:
1. Alterations in the regulation of affective impulses.
2. Alterations in attention and consciousness.
3. Alterations in self-perception.
4. Alterations in perception of the perpetrator.
5. Alterations in relationship to others.
6. Somatization and/or medical problems.
7. Alterations in systems of meaning (p. 88).
These aftereffects of complex trauma add a layer of complexity to the treatment, creating additional challenges that are not present in classic PTSD patients, as trust and secure attachment are critical for establishing a safe environment (Tarocchi et al., 2013).
While exposure therapy is a common treatment for PTSD patients, one issue in working with individuals who endorse complex trauma is that they may face retraumitization if they have not first established and learned how to preserve feelings of safety. Following assessment, Courtois (2008) argues that the sequencing of the treatment is important and should be especially cautious in the beginning while the foundations of safety and emotion regulation are being established. She presents a three-stage model that should be
employed.