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Complex traumatic stress disorders in adults.

It is a challenge to present evidenced-based guidelines for the treatment of disorders that are not even included in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association [APA], 1994). The DSM, however, is a work in progress. With the projected release of the DSM V (APA, 2009) in 2012, I believe there is now a significant enough body of research to direct diagnosis and treatment options for clients with complex trauma histories.

In this article I will first discuss issues of the diagnosis and nomenclature of trauma-based disorders in adults, including definitions of complex trauma, and complex traumatic stress disorders. I will then address symptoms, and treatment guidelines, followed by some theological reflections.

Suggested Diagnostic Categories for Trauma-based Disorders

There has been a lot of confusion, even controversy, about how trauma-based disorders should be classified. Following is a brief description of some of the terms found in the literature and some history of their use.

Posttraumatic Stress Disorder

As early as 1859, connections were being made between psychological trauma and mental illness. However, the war neuroses of World Wars I and II, as well as studies on concentration camp survivors, brought further attention to this association (van der Kolk, Weisaeth, & van der Hart, 2007). The idea that trauma could result in specific clusters of symptoms became formalized by the inclusion of posttraumatic stress disorder (PTSD) in the Diagnostic and Statistical Manual of Mental Disorders (3rd ed.; DSM-III, APA, 1980), precipitated by awareness of the psychological problems experienced by returning Vietnam War veterans in the late 1970's (van der Kolk, Roth, Pelcovitz, Sunday, & Spinazzola, 2005).

PTSD Field Trials and Disorders of Extreme Stress Not Otherwise Specified

From its inception as a diagnostic category, it was clear that the core PTSD symptoms of re-experiencing, avoidance/numbing, and hypervigilance did not explain all of the symptoms exhibited by trauma survivors, particularly those of children and adults who had experienced chronic or severe interpersonal trauma (van der Kolk & Courtois, 2005). Therefore, in preparation for the development of the DSM-IV, a PTSD field trial was undertaken. Van der Kolk, Roth, and associates (2005) summarized the field trial indicating that one of its goals was to explore whether the symptoms described in the literature on child abuse, concentration camp victims, and victims of domestic battering, were better explained by a category of symptoms other than those of PTSD. Among the results were those that indicated that prolonged, interpersonal trauma that begins at an early age can result in a cluster of symptoms that is in addition to those that constitute criteria for PTSD.

The working group used the term disorders of extreme stress not otherwise specified (DESNOS), a term first suggested by Herman (1992), to refer to this symptom cluster, and recommended its inclusion as a separate diagnostic category. However, the working group was "over-ruled at higher levels" (Herman, 2009, p. xiii) so that DESNOS was relegated to the "Associated Features" of PTSD in the DSM-IV (APA, 2004). While the majority of those identified as DESNOS in the field trial also met PTSD criteria, subsequent studies have found that DESNOS criteria have been met by many trauma patients who do not meet DSM-IV criteria for PTSD (van der Kolk, Roth, et al., 2005).

Type I versus Type II Trauma

Terr (1991) classified trauma into two categories: Type I and Type II. Type I trauma was conceptualized as single-incident trauma, such as a natural disaster, terrorist attack, single incident of abuse, or witnessing a violent act. In contrast, Type II trauma referred to complex or repetitive trauma such as ongoing abuse, domestic violence, or genocide. Sequelae of these types of exposure would be parallel to the diagnostic categories of PTSD and DESNOS discussed above.

Complex Trauma and Complex Traumatic Stress Disorders

Treating Complex Traumatic Stress Disorders (Courtois & Ford, 2009a), is the most comprehensive work to date on the types of trauma disorders that are not adequately reflected in a PTSD diagnosis. They have chosen to use the terms complex (psychological) trauma to describe a cluster of specific traumatic stressors, and complex traumatic stress disorders to refer to the symptom configurations associated with a history of complex trauma. For convenience I will use these terms in the rest of the current article since despite slight variations, they encompass the core components of the other terms discussed.

Nature and Sequelae of Complex Trauma

Complex psychological trauma has been defined as "involving traumatic stessors that (1) are repetitive or prolonged; (2) involve direct harm and/or neglect and abandonment by caregivers or ostensibly responsible adults; (3) occur at developmentally vulnerable times in the victim's life, such as early childhood; and (4) have great potential to compromise severely a child's development" (Courtois & Ford, 2009b, p. 1).

Trauma in early childhood can have a particularly adverse lifelong impact. Neurological and cognitive functions are rapidly formed at this time, laying the necessary psychological and biological foundations crucial for subsequent healthy development (Ford, 2009; Putnam, 1997). When these processes are blocked or interrupted as a result of trauma, the impact can be enormous. Effects include affect dysregulation and impaired self concept (Wilson, 2004), dissociation (DePrince & Freyd, 2007; Zelikovsky & Lynn, 2002), somatic dysregulation (Nijenhuis, Van der Hart, Kruger, & Steele, 2004; Ogden, Minton & Pain, 2006), disorganized attachment patterns (Lyons-Ruth, Dutra, Schuder, & Bianchi, 2006; Pearlman & Courtois, 2005), and spiritual alienation (Tracy, 2005) leading to intrapsychic and relational disturbances in later life. These are in addition to the PTSD symptoms of re-experiencing (e.g., intrusive thoughts, images, flashbacks, nightmares, increased psychological distress such as anxiety, fear, terror, sadness, etc. on exposure to trauma-related stimuli), avoidance/numbing (e.g., passive and active avoidance tendencies, memory loss, diminished interest in normal activities, social detachment, emotional anesthesia), and hyperarousal (e.g., sleep cycle disturbances, feelings of anger, irritability and hostility, impairment in cognitive processing of information, excessive alertness to threat or danger, abnormal startle response; Wilson & Keane, 2004).

Incest, and/or clergy abuse, can be particularly difficult for children to integrate into their experience (Flynn, 2008; Langberg, 1997), as the very individuals who are supposed to nurture and protect them are the ones who are injuring them. This has been called betrayal trauma in the literature; a social dimension of trauma that occurs "when the people or institutions on which a person depends for survival violate that person in a significant way" (Freyd, DePrince, & Gleaves, 2007, p. 297). Particularly if abuse is at the hands of caregivers, development of a secure psychological base (Bowlby, 1988) and foundation for developing basic relational trust (Erikson, 1950/1963) can be affected, resulting in possible infant attachment disorganization (Lyons-Ruth et al., 2006). These early attachment deficits often have a negative impact on later adult attachment and relational styles (Pearlman & Courtois, 2005).

Treatment

Courtois, Ford and Cloitre (2009) pointed out that there is limited treatment outcome research on complex traumatic stress disorders as studies looking at trauma have focused exclusively on PTSD and have often screened out participants with symptoms of complex trauma. There is, however, 25 years worth of literature written by practitioners who have been conducting therapy with these clients, which can be used as an "evolving evidence base for preliminary treatment recommendations and provisional best practices for complex traumatic stress disorders" (p. 84; italics as in original).

Helpful treatment approaches and strategies have included both individual and systemic models. Individual approaches include contextual therapy, cognitive-behavioral therapy, contextual behavior trauma, experiential and emotion-focused therapy, sensorimotor psychotherapy, and pharmacotherapy. Systemic orientations include internal family systems therapy, couple therapy, family systems therapy, and group therapy. There is not space in this article to describe each of these models (see Courtois & Ford, 2009a). I will, however, address some of the general treatment principles that over-ride specific theoretical orientations.

Three-Phase Model

Almost two decades ago, Judith Herman (1992) suggested a three-phase treatment model for survivors of complex trauma. This is currently the standard practice for treatment (Ford, 2009). Although the names given to the phases have varied somewhat according to the individual author, the idea behind each phase has been consistent. Treatment tends to be longer-term than for PTSD alone, sometimes lasting decades, and seldom being of any significant help in fewer than 10-20 sessions (Courtois et al., 2009). Clients who are unwilling or unable to commit to extensive treatment can make some gains through Phase I work alone. Following are some considerations for therapeutic work within each of these phases.

Phase 1: Safety and Stabilization

When a counselee presents with re-experiencing symptoms in the form of flashbacks or nightmares of traumatic events, the temptation for some may be to jump into processing the content of the memories. While this may be helpful for single incident PTSD clients, for complex trauma clients, this can be the equivalent of opening Pandora's Box, as a multitude of memories may compete for attention, overwhelming and further destabilizing the client. Clients with low ego-strength, limited support systems, or those who are unable to commit to long-term therapy may not have the resources to move beyond this phase.

Safety within the therapeutic relationship. As complex traumatic stress disorders are the result of relationship trauma, particular attention to the development of trust within the therapeutic relationship is crucial. Issues around trust will often resurface even years into therapy.

Safety from external dangers. It is important to assess if the client is currently in danger of re-victimization. For example, a survivor of child abuse may currently be at risk for domestic violence.

Safety from self. Contracting for suicide or self-harm may be important. If clients are highly dissociative, this may involve negotiating with dissociated parts of self (see following section on Dissociation). Use of visual imagery to establish a sense of an inner "safe place" is an option.

Development of a support network. Due to the relational deficits that tend to be a part of complex traumatic stress disorders, such clients are often socially isolated. Helping individuals connect to community resources can free the therapist from the daunting task of being the sole support person. For Christian clients, churches which have some understanding of complex traumatic stress disorders can be potentially very helpful.

Symptom stabilization. Cognitive-behavioral techniques show the greatest evidence base for reducing PTSD symptoms, and increasing positive affect and cognitive appraisals (Ford, 2009). Journaling, prayer, time spent with friends, and attention to physical self care (e.g., exercising, eating well) are techniques that have been discussed at length in the child abuse literature (e.g. Bass, 1988; Langberg, 1999).What has been found to be particularly useful is making use of a client's abilities to dissociate in order to help control symptoms (see following section on Dissociation).

Phase II: Processing of Traumatic Memories

The primary task of this phase is "safe self-reflective disclosure of traumatic memories and associated reactions in the form of progressively elaborated and coherent autobiographical narrative' (Courtois et al., 2009, p. 93). Basically, this means that survivors need to be able to tell the story of their trauma (Herman, 1992/1997). However, this does not involve a therapist merely attempting to facilitate the trauma disclosure, or allow for abreactions (Ford, 2009). A self-reflective process is essential in helping the survivor integrate not only cognitive aspects, but affective, somatic, and behavioral components of their experience (cf., Braun's [1988] BASK model of dissociation). For example, clients are encouraged to deal with their emotions of anxiety, grief and mourning, shame, rage, fear, hatred, and so on, but in a carefully titrated fashion so that functioning is not compromised (Herman, 1992/1997; Langberg, 1997).

The degree of attention that is given to dealing with affect will depend somewhat on the therapist's theoretical orientation. However, even though some cognitive-behavioral approaches to memory reconstruction have been found to be helpful, clinicians are cautioned to consider carefully adapting their approaches to include more affective work in order to meet the needs of specific clients (Courtois et al., 2009).

Phase 3: Reintegration

This phase involves both consolidation of previous work, as well as increased preparation for adaptive living in the present and future. Herman (1992/1997) discussed some of the challenges faced by clients during this phase as: helping clients learn how to appropriately face danger (i.e., learning to fight), developing a non-trauma identity, reconnecting with others, and finding meaning in their trauma history. Sexual functioning, parenting, continued work on unresolved developmental deficits, self-regulation, and ending the therapeutic relationship well, are some of the other areas that possibly need attention before therapy is terminated (Courtois et al., 2009).

Use of a Client's Dissociative Capacities as a an Aid to Treatment

There is such a strong association between complex trauma (particularly a history of early childhood abuse) and dissociation (both dissociative disorders and dissociative experience; Gingrich, 2005a; 2009) that it merits consideration here. While the dissociative symptoms of dissociative amnesia, depersonalization, derealization, identity confusion, and identity alteration are front and center in the dissociative disorders (Steinberg, 2000), they can also be clues to complex traumatic stress disorders, and thereby aid in accurate diagnosis.

As mentioned earlier, awareness of a client's use of dissociation as a defense against trauma can greatly aid in treatment. In my experience, in Phase I work, flashbacks, nightmares, somatic symptoms (including "body memories"), problems with affect regulation, and a myriad of other symptoms can be managed relatively easily by making use of the client's ability to dissociate to negotiate around symptom manifestation. For example, if Mary is a client who is exhibiting reexperiencing symptoms in the form of constant nightmares, whether or not she fits the criteria for a dissociative disorder, I would ask "all parts of Mary" to listen in. After briefly explaining who I am and why the nightmares are a problem, I would ask if "all of Mary" would agree to stop the nightmares, promising to deal with the content at a later date (i.e., in Phase II of the therapy process). Similarly, in Phase II, if a trauma narrative is not complete, or the meaning of the content not clear, I would ask "the part of Mary that knows" to clarify. In this way conscious, cognitive processes can be by-passed, and unconscious, dissociated aspects of the client's self that are associated with traumatic experiences can be readily accessed. While this approach may seem unusual to nondissociative clients (or some clinicians!), I have found that clients who do dissociate respond very well, resulting in much higher functioning.

Theological Reflections

The very existence of complex trauma, is an indication of the depth and breadth of depravity to which humankind has fallen after Eve's and Adam's disobedience to God (Genesis 2). However, not only are our sinful natures clearly evident in the perpetrators of relational violence, but the results of the Fall are seen in the distortion of the Imago Dei as experienced by the victims. Although biblical scholars have offered various explanations for the Imago Dei, a strong argument exists for a relational interpretation (Tracy, 2005). As mentioned earlier, complex trauma survivors often struggle with attachment to others, both in their relationships to other people, as well as in their relationship to God.

Particularly devastating is child abuse at the hands of caregivers who purport to be Christians, particularly if Scripture is used to justify the abuse. For example, the admonition for children to obey their parents (Eph. 6:1) has been used as a rationalization by abusive parents for their violent behavior. How can a child who has been beaten and/or raped by her father be expected to have a healthy view of God as Father? Similarly, when clergy have been the perpetrators, development of a healthy spirituality is a particular challenge (Flynn, 2008).

A skilled Christian therapist can be particularly effective with these clients if appropriate attention is paid to the therapeutic relationship. As the therapist exhibits the core facilitative conditions (Rogers, 1959) and trust develops in the therapeutic relationship, clients can catch a glimpse, perhaps for the first time, of God's unconditional love for them.

Explicit spiritual interventions, such as in-session prayer and use of Scripture, may be helpful to complex trauma survivors whose relationship to God has not been significantly damaged. However, great care must be taken to not impose such interventions, however well-intended, as they may be experienced as retraumatizing spiritual abuse. Of particular danger are deliverance sessions, whether occurring inside or outside of therapy, intended to deal with demonic influence, particularly with highly dissociative clients (Gingrich, 2005b). Instead, giving permission for such clients to process their ambivalence not only towards God, but also other Christians and the church, can further both psychological and spiritual healing. As clients become more whole, explicit spiritual interventions may become an option, as long as careful informed consent is obtained, with no hint of even subtle coercion on the part of the therapist.

Conclusion

I have barely scratched the surface of how to conceptualize complex traumatic stress disorders and treat survivors of complex trauma. There are, however, resources that can be of immense help to readers who want to know more. The International Society for the Study of Trauma and Dissociation (ISSTD) is an excellent one. It focuses much of its attention on helping educate and train clinicians to treat complex traumatic stress disorders and dissociative disorders. The web-site (www.isst-d.org) contains an extensive bibliography of research articles and assessment instruments. It also lists component groups in geographical locations world-wide, as well as information about conferences, training opportunities, and client referral sources. While it is a secular organization, it has many Christians among its members.

Space did not allow me to address the issue of assessment. However, several chapters in Courtois and Ford's (2009a) book deal with specific aspects of assessment. Assessing Psychological Trauma and PTSD (Wilson & Keane, 2004) is another valuable resource. It is quite comprehensive, including information about assessment instruments intended to assess complex trauma and dissociation, as well as PTSD.

Some people are incredulous when I tell them that my favorite course to teach is "Counseling for Trauma and Abuse," and that I love working with clients who have experienced complex trauma! It is true that hearing the trauma narratives is horrendous, and seeing the brokenness of clients with complex traumatic stress disorder can be excruciating. The negative effects on the clinician can potentially lead to vicarious traumatization (Kadambi & Ennis, 2004). However, therapists can learn a lot about facing adversity from the remarkable resiliency of many of these clients (Harvey & Tummala-Narra, 2007), thereby developing a sense of vicarious resilience themselves (Hernandez, Gangsei, & Engstrom, 2007). There is some indication that therapists who do more of this kind of work experience greater spiritual satisfaction and well-being (Brady, Guy, Poelstra, & Brokaw, 1999). For me, the difficulties that are inherent in working with clients with complex traumatic stress disorders are vastly outweighed by the privilege of witnessing the miracle of transformation as the hand of the Great Physician brings healing and wholeness to individuals whose lives, even their very selves, have been so shattered.

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Heather Davediuk Gingrich

Denver Seminary

Heather Davediuk Gingrich, Ph.D., is Associate Professor of Counseling at Denver Seminary.

Correspondence may be addressed to Heather Davediuk Gingrich, Ph.D., Associate Professor of Counseling, Counseling Division, Denver Seminary, 6399 S. Santa Fe Dr., Littleton, CO, 80120; heather.gingrich@denverseminary.edu
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Title Annotation:Research into Practice
Author:Gingrich, Heather Davediuk
Publication:Journal of Psychology and Christianity
Date:Sep 22, 2009
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