Info about Treatment - Updated 05 May 2022

[Kizzie]

There are numerous types of approaches used to treat Complex PTSD although most are based on treatment of PTSD and/or other issues such as anxiety and depression. As Ford and Courtois (2020) suggest in their review of existing therapeutic models,  "the crucial question of when and for whom different evidence-based treatment models or their components are recommended remains unanswered". That said, there are a number of commonly used models they found to be effective in the treatment of Complex PTSD including:  Eye Movement Desensitization and Reprocessing (EMDR), Emotion Focused Therapy, Prolonged Exposure Therapy, Cognitive Behavioural Therapy (CBT), and Interpersonal Psychotherapy.  They also point to promising emerging models/approaches including: sensorimotor psychotherapy, experiential therapy, and various mindfulness approaches.

..there is no need for despair because, along with all the other things we have learned about trauma over the course of the past several decades, a number of treatment methods have been developed, tested, and proven effective. Christine Courtois, PhD

....the past 20 years have brought us extraordinary, evidence-based breakthroughs in the treatment and healing of trauma. In a wide range of fields, psychologists, neuroscientists, pioneering therapists, and traditional healers are making enormous progress in helping us to recover—and to turn our energies toward our greater dreams and life purpose. - The Healing Trauma Summit, June 2018

Dr. Judith Herman (Ford & Courtois, 2020) suggests researchers and clinicians must next focus on what components of the numerous models are most effective in treating complex trauma. "Since it is not realistic to expect that practitioners will become expert in numerous different, specialized techniques, some researchers now suggest that we might be ready to shift our focus from studies of competing models to studies that elucidate the common features of effective therapies" (2020).  Given many (most) survivors experience difficulty wading through the numerous approaches and choosing one that works for them, having fewer but more specific, evidence based models for Complex PTSD would be a welcome change.

For further information about current therapeutic models/approaches, here are two bibliographies of research articles and books. While written for researchers and clinicians for the most part, they can be useful in helping you to dig a little deeper into various models. Beyond these resources a simple Google search will bring up loads of articles about various treatments for trauma (a word of caution here - not all models/approached are evidence-based).

A Word About More Accessible Treatment

Therapy for Complex PTSD until recently has only been available in large cities where therapists with knowledge and experience of this type of trauma tend to cluster. More and more, however, treatment is offered virtually.  While this means therapy is now more accessible geographically, it remains financially inaccessible for most survivors. In most countries, a limited number of sessions are covered by government or Insurance plans, after which survivors must pay out of pocket and it is prohibitively expensive.  Sessions run from $175 to $250  and what this means is that survivors go without treatment or pay dearly $700 to $1,000 monthly.  In short, many survivors simply cannot afford to get well. This must change. Mental health is not separate from physical health, they are intertwined and should be treated as such. Hopefully as we find each other in forums like this, as more trauma organizations serving complex trauma survivors are formed, we will join our voices and make enough noise to get this message to the ears that need to hear it. 

Guidelines for Treatment

Cloitre, M., Courtois, C., Ford, J. Green, B., Alexander, P., Briere, J., Herman, J. Lanius, R., Pearlman, L., Stolbach, B., Spinazzola, J. & van der Hart, O. (2012). ISTSS Expert Consensus Treatment Guidelines for Complex PTSD in Adults. International Society for Traumatic Stress Studies.

Cloitre, M., Courtois, C., Charuvastra, A., Carapezza, R., Stolbach, B. & Green, B. (2011). Treatment of Complex PTSD: Results of the ISTSS expert clinician survey on best practices. Journal of Traumatic Stress, 24 (6)

Kezelman, C. & Stavropoulos, P. (2019). Practice Guidelines for Clinical Treatment of Complex Trauma, Australia: Blue Knot Foundation

Kezelman, C. & Stavropoulos, P. (2012). Practice Guidelines for Treatment of Complex Trauma and Trauma Informed Care and Service Delivery, Australia: Blue Knot Foundation

[Kizzie]

Finally primary care physicians are beginning to ask about a history of trauma -  ACEs (Adverse Childhood Experiences): One Family Physician's Experience by By Dr. Tahmeena Ali, August, 2019. Here's a short excerpt:

Now, I ask all patients: young and old; new to my practice and established for years; male, female or trans, to complete an ACEs questionnaire in my clinic.  I compliment all my patients with any ACE score on their resilience and ask how I can support them. I acknowledge the pain they endured and educate them on how that early trauma can affect their biology and how it might be effecting their health now.

Awesome 

[Blueberry]

Thanks for all these links, Kizzie! I've just checked this one out: Cloitre, M. (2015). The ''one size fits all'' approach to trauma treatment: Should we be satisfied? European Journal of Psychotraumatology, 6. https://doi.org/10.3402/ejpt.v6.27344   
An interesting, informative read. Though probably what most of us know instinctively already. It's good that researchers are seeing it.

[Kizzie]

This paper was researched and written by Dr. Karen Triesman who has done some great work in terms of trauma. 

Trauma-inducing and trauma-reducing health and medical experiences

[Kizzie]

Relational Healing in Complex PTSD, by Pete Walker, Sept 2008

Those with Complex PTSD-spawned attachment disorders never learn the communication skills that engender closeness and a sense of belonging. When it comes to relating, they are typically plagued by debilitating social anxiety, and social phobia when they are at the severe end of the continuum of PTSD. Many of the clients who come through my door have never had a safe enough relationship. Repetition compulsion has compelled them to unconsciously seek out relationships in adulthood that traumatically reenact the abusive and/or abandoning dynamics of their childhood caretakers. For many such clients, we are their first legitimate shot at a safe and nurturing relationship; and if we are not skilled enough to create the degree of safety they need to begin the long journey towards developing good enough trust, we may be their last.

The Tyranny of Time: How Long Does Effective Therapy Really Take?, by Jonathan Shedler & Enrico Gnaulati, April 2020

It's tempting to wonder if dropout rates reflect the poor job we're doing in our cherished profession to train therapists to hone the human traits that make meaningful therapy possible and have mountains of research backing: empathy, understanding, genuine regard, and skill at building an alliance around the shared task of the therapy work. Clients need to know their therapist not only cares enough to listen, but knows how to listen carefully enough to hear what matters. Clients need plenty of space and time to tell their agonizing life stories in the nonlinear, scattershot way distressed humans are apt to do. Silences leave room for deeper feelings and realizations to bubble up. Subtle head nods, wry smiles, and knowing groans by the therapist are reminders to clients that they are being heard.

[Kizzie]

Scientists Unpack How the Brain Separates Present from Past Dangers—While Signaling Safety

Some science to explain why the past lives on in us, why we can't simply forget our trauma and why/how we have difficulty distinguishing between safety and threat in the present because of how the past has wired our brain/nervous system.  It's all about proteins and expressing/inhibitory neurons.

They found that protein synthesis in specific inhibitory neurons in the amygdala—Somatostatin-expressing neurons—is crucial for storing information about the cued threat whereas protein synthesis in PKCδ-expressing neurons is necessary for storing complementary information about safety cues.

Activity in these populations of neurons was previously shown to occur in processing threat-related cues; however, this is the first study to connect the necessity of new protein synthesis in these neurons to the stabilization of long-term emotional memories.

[Kizzie]

Treating Adult Survivors of Childhood EmotionalAbuse and Neglect: A New Framework - Article about Component Based Psychotherapy which addresses symptoms of relational trauma/CPTSD incl relationship, regulation, dissociation & narrative. Emphasizes the therapist & contextual factors 

One of the few bits I've read about the assumption that PTSD therapeutic models are suitable for survivors with Complex PTSD:

....despite the great proliferation of approaches to the treatment of psychological trauma, the majority of these models and the research that supports their effectiveness have been principally designed to address symptoms of one specific psychiatric diagnosis, post traumatic stress disorder (PTSD). Although undoubtedly a pernicious and pervasive condition, epidemiological research in adult and child populations has clearly established that PTSD is neither the sole nor even most common condition experienced by survivors in the after-math of trauma.

Yup.     

[BeeKeeper]

Excellent and informative article Kizzie! Thanks.

My 2 cents:

Part of the preface to their intro to Component-Based Psychotherapy.

"Despite nearly a half-century of attention directed in psychiatry, psychology, social work, and allied professions to the development of treatment models for victims of psychological trauma, resulting in the establishment of nearly 100 distinct evidence-based or promising practices, to date not a single one of these models has been specifically designed to target the effects of childhood emotional abuse and neglect in adult or (for that matter) child survivors."

In reading further they specifically outline not only the components, but also the ROLE of the therapist in each "stage" or step. Very positive and covers a lot of the bases.

[Kizzie]

I really like the components the model focuses on - very much in line with the ICD-11 Complex PTSD diagnosis.  That said I would like to see a somatic component because as we all know relational trauma is quite physical not just psychological.

One thing I can say is that I'm relieved/delighted to see a therapy designed specifically for us. PTSD has blotted us out in many ways despite the fact we suffer from 6 versus 3 symptoms.  Seems a no-brainer we would require different/expanded therapy. 

[Kizzie]

Here's a link to an updated list of books about treatment of Complex PTSD/Relational Trauma Response:

https://www.outofthestorm.website/books-about-treatment

[Kizzie]

Here's a link to the newly updated list of research into treatment and assessment of complex trauma -
https://www.outofthestorm.website/bibliography-assessment-treatment.

Academic articles to be sure but you never know when something will be useful/helpful to understanding/recovery. Also, just knowing researchers are investigating complex trauma can be reassuring.

[Kizzie]

I came across a book that captures some of what I'm starting to feel is crucial to healing from relational trauma - reducing shame (of course, this part is much written about), while increasing pride - not written about quite so much.

Shame, Pride, and Relational Trauma: Concepts and Psychotherapy by Ken Benua, 2022.

Description:

Shame, Pride, and Relational Trauma is a guide to recognizing the many ways shame and pride lie at the heart of psychotherapy with survivors of relational trauma. In these pages, readers learn how to differentiate shame and pride as emotional processes and traumatic mind/body states. They will also discover how understanding the psychodynamic and phenomenological relationships between shame, pride, and dissociation benefit psychotherapy with relational trauma. Next, readers are introduced to fifteen attitudes, principles, and concepts that guide this work from a transtheoretical perspective. Therapists will learn about ways to conceptualize and successfully navigate complex, patient-therapist shame dynamics, and apply neuroscientific findings to this challenging work. Finally, readers will discover how the concept and phenomena of pro-being pride, that is delighting in one's own and others' unique aliveness, helps patients transcend maladaptive shame and pride and experience greater unity within, with others, and with the world beyond.

Pride and dignity are words that are starting to come up as antidotes to the ravages of relational trauma and I love this. We need to hold our heads high, come out of the dark, break our silence and be ever so proud we survived IMO.