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					  Advances in the Understanding
   and Treatment of Trauma:
Variable Adaptations, Variable Treatments

          Christine A. Courtois, Ph.D.
          Psychologist, Private Practice
                Washington, DC
             Types of Trauma
u   Accidental

u   Interpersonal

u   Combination
    Interpersonal Trauma:
“A break in the human lifeline”
                  Robert J. Lifton

  Self and interpersonal effects
       brought to treatment
   Types of Traumatic Stressors
Emotional Trauma

“It is the essence of emotional trauma that it
  shatters…absolutisms, a catastrophic loss of
  innocence that permanently alters one‟s
  sense of being-in-the-world.”
                (Heidegger, quoted in Stolorow, 2007)
              Types of Trauma
u   Type I

u   Type II

u   Overlap
               Types of Trauma
u   Attachment/Relational

u   Emotional

u   Betrayal

u   Secondary/ “second injury”/institutional
      What is Complex Trauma?
u   Repetitive, chronic
u   Cumulative
u   Often in attachment relationships
    • Entrapment & betrayal; second injury
u   Often over the course of childhood
    • Impacts development
u   Other…
       Trauma and Development
u   Attachment trauma
u   Attachment style and Inner Working Model
    • Secure
    • Insecure
    • Disorganized
u   Lack of self validation/reflection
u   Effect on brain development
    • Survival brain vs. learning brain
       Trauma and Development
u   Can effect development starting at the
    neuronal level
    • Neurons that fire together wire together
u   Can affect brain structure
u   Can affect brain function
u   Right brain/sensory-motor imprint
u   Left brain development impeded
    • There may be no words
    • Speechless terror
        Types of Traumatic Stressors
n   Attachment/Relational Trauma
    u occurs in attachment relationships with primary
       F insecurity of response and availability
       F mis-attunement, non-response
       F lack of caring and reflection of self-worth
       F caregiver as the source of both fear and comfort
    u includes DV and child abuse of all types
       F often “on top of”/in context of attachment insecurity
       F neglect, abandonment, non-protection, non-
         response, sexual and physical abuse and violence,
         verbal assault
    Risk/Vulnerability and Protective
u   Temperament
u   Gender
u   Personal history
    • Previous trauma/PTSD
u   Culture
u   Community
    • Support or not
     Posttrauma Adaptations
                      (adapted from Wilson, 1989)

Note: most individuals who are seriously
  traumatized have posttraumatic reactions;
  not all develop posttraumatic disorders.
        DSM-IV Criteria: PTSD
u   A. Exposure or experience
u   B. Persistent reexperiencing, intrusions,
    dreams of trauma, distress at re-exposure
u   C. Persistent avoidance of stimuli
    associated with the trauma and numbing
u   D. Persistent symptoms of increased
Posttraumatic Diagnoses, DSM-IV

u   Dissociative Disorders
    •   Depersonalization
    •   Dissociative fugue
    •   Dissociative amnesia
    •   Dissociative Identity Disorder
         – related to severe childhood trauma
    • DDNOS
u   Associated Disorders: Axis I, II, & III
Limbic System of the Brain
     Limbic System of the Brain
     Posttraumatic Stress Disorder
u   A complex dynamic entity
    • fluctuating, not static
    • variable in form, presentation, course, degree of

u   A multimensional bio-psycho-social-
                         stress response syndrome
u   An allostatic condition
   Posttraumatic Stress Disorder
Allostasis: “refers to the body‟s effort to
  maintain stability through change when
  loads or stressors of various types place
  demands on the normal levels of adaptive
  biological functioning…The failure to
  “switch off” allostatic mechanisms once
  the threat or requirement to respond has
  terminated, however, begins a complex
  process of “wear and tear” on the nervous
  and hormonal systems”.
                      ( Wilson, Friedman, & Lindy, 2002, p. 9)
One‟s thermostat is broken
     Stress overload
Post-trauma Responses and Disorders
u   Complex Posttraumatic Stress Disorder/
    (DESNOS) “PTSD plus”
    • related to severe chronic abuse, usually in
      childhood, and attachment disturbance
    • usually highly co-morbid
    • often involves a high degree of dissociation
u   Dissociative Disorders
    • associated with disorganized attachment and/or
      abuse in childhood
    • can develop in the aftermath of trauma that
      occurs any time in the lifespan
    • DDNOS may be the most common DD (as
      currently defined in the DSM)
    Complex Posttraumatic Stress Disorder
    Disorders of Extreme Stress Not Otherwise Specified

u   Designed to account for developmental
    issues, co-morbidity, memory variability
    and reduce stigma
u   Co-morbidity:
    • distinct from or co-morbid with PTSD
    • other Axis I, mainly:
       – depressive and anxiety disorders
       – substance abuse/other addictions
       – impulse control/compulsive disorders
    • Axes II and III
                PTSD in Children
u   No available childhood PTSD or DD
    diagnosis in the DSM
u   Children respond as children, not as little
    • work of Terr, Putnam, Pynoos, Perry has been
      instrumental to early understanding of childhood
u   Children are very vulnerable, yet resilient
    • on average, takes less to traumatize them
(Proposed) Developmental Trauma Disorder
                                   (van der Kolk, 2005)

n   Domains of impairment in children
    exposed to complex trauma:
    u Attachment/relationship capacity
    u Biology
    u Affect regulation
    u Dissociation
    u Behavioral control
    u Cognition
    u Self-concept
     Symptom Categories and Diagnostic Criteria
        for Complex PTSD/DESNOS

u   l. Alterations in regulation of affect and
    •   a. Affect regulation
    •   b. Modulation of anger
    •   c. Self-destructiveness
    •   d. Suicidal preoccupation
    •   e. Difficulty modulating sexual involvement
    •   f. Excessive risk taking
u   2. Alterations in attention or consciousness
    • a. Amnesia
    • b. Transient dissociative episodes and
    Symptom Categories and Diagnostic Criteria
       for Complex PTSD/DESNOS
u   3. Alterations in self-perception
    • a. Ineffectiveness
    •   b. Permanent damage
    •   c. Guilt and responsibility
    •   d. Shame
    •   e. Nobody can understand
    •   f. Minimizing
u   4. Alterations in perception of the
    • a. Adopting distorted beliefs
    • b. Idealization of the perpetrator
    • c. Preoccupation with hurting the perpetrator
Symptom Categories and Diagnostic Criteria
   for Complex PTSD/DESNOS
u   5. Alterations in relations with others
    • a. Inability to trust
    • b. Revictimization
    • c. Victimizing others
u   6. Somatization
    • a. Digestive system
    •   b. Chronic pain
    •   c. Cardiopulmonary symptoms
    •   d. Conversion symptoms
    •   e. Sexual symptoms
u   7. Alterations in systems of meaning
    • a. Despair and hopelessness
    • b. Loss of previously sustaining beliefs
           Complex PTSD/DESNOS
u   Controversial
u   Not a formal DSM diagnosis: Associated
    Feature of PTSD
u   Nevertheless, a useful way of organizing
    symptoms and treatment
u   A less pejorative way of understanding and
    approaching the treatment of those who
    often look and behave like BPD
u   Empirical investigation underway
            Attachment Organization
         (Ainsworth, 1978; Liotti, 1992; Main, 1986, Siegel, 1999)

u   Child style                        u   Adult style
    • secure                                • autonomous
    • insecure-avoidant                     • dismissive/detached
    • insecure-dismissing/                  • preoccupied/anxious
      resistant/ambivalent                    (“velcro”)
    • insecure-disorganized/                • fearful/anxious
      disoriented/dissociated                  unresolved/dissociative
         Attachment Relationships
u   “…are crucial to the process of integration.
    The difficulties that bring patients to
    treatment usually involve unintegrated and
    undeveloped capacities to feel, think, and
    relate to others (and to themselves) in ways
    that „work‟”
u   Paraphrasing Bowlby, “The therapy
    relationship involves sanctioning patients to think
    thoughts, experience feelings and consider actions
    that parents have forbidden.” (Wallin, 2007)
           Implications for Treatment
u   Attachment abuse including ongoing neglect and
    failure to respond and soothe a child (neglect) is
    implicated in the development of the DD‟s
     • a wider base beyond overt physical and sexual
       abuse from which to understand DD‟s
u   The emphasis in treatment is shifted back toward
    education and the intrapsychic and interpersonal
    patterns started early in life and away from solely
    working through the other forms of childhood and
    adult trauma
          Evidence-Based Practice
u   Best research
u   Clinical expertise
u   Patient values,
    identity, context

    American Psychological
    Association Council of
    Representatives Statement,
    August 2005
EBT (Evidence-Based Therapy)

     is NOT the same as

 EST (Empirically-Supported
         Evidence-Based Practice
u   Best research evidence, including:
    •   Effectiveness
    •   Public health
    •   Health services
    •   Health care economics
       Evidence-Based Practice
u   Clinical expertise, including:
    • Clinical assessments, judgments,
    • Reflection & consultation
    • Interpersonal expertise/use of self
       – ability to collaborate, not exploit
       – ability to stay “steady state”, attune to client
    • Understanding of client‟s contexts, values
    • Using available resources
    • Working from theory
       Evidence-Based Practice
u   Patient identity, values, contexts
    • Ethnicity, race, culture, language,
      gender, sexual orientation, religion,
      age, illness or disability status
    • Treatment acceptability
    Expert Consensus Guidelines for “Classic PTSD”
u   ISTSS Guidelines (Foa, Friedman, & Keane, 2000,
u   Journal of Clinical Psychiatry (2000)
u   American Psychiatric Association (2003)
u   Clinical Efficiency Support Team (CREST,
    Northern Ireland, 2003)
u Veterans‟ Administration/DoD (US, 2004)
u National Institute of Clinical Excellence (NICE,
    UK, 2005)
u   Australian Centre for Posttraumatic Mental Health
     Other Expert Consensus Guidelines
u   Dissociative Disorders
    • Adult (ISSD, 1994, 1997, 2005, in revision
    • Children (ISSD, 2001)
u   Delayed memory issues
    • Courtois (1999; Mollon, 2004)
u   Complex trauma (under development)
    • (Courtois, 1999; CREST, 2003; Courtois &
      Ford, 2009; ISTSS complex trauma expert
      consensus survey, in process)
    Effective Treatments for PTSD*
u   Psychopharmacology
u   Psychotherapy (CBT, especially)
u   Psych-education
    Other supportive interventions

*Few studies have evaluated using a combination of
  these approaches although combination treatment
  commonly used and may have advantages
            Treatment Goals
u   educate about and de-stigmatize PTSD sx
u   increase capacity to manage emotions
u   reduce co-morbid problems
u   reduce levels of hyperarousal
u   re-establish normal stress response
u   decrease numbing/avoidance strategies
u   face rather than avoid trauma, process
    emotions, integrate traumatic memories
              Treatment Goals
u   restore self-esteem, personal integrity
    • normal psychosexual development
    • reintegration of the personality
u   restore psychosocial relations
    • trust of others
    • foster attachment to and connection with others
u   restore physical self
u   restore spiritual self
u   prevent re-victimization/reenactments
      Treatment Principles

“First, do no more harm”

Treatment can help and treatment can hurt
      both the helper and the client
          Treatment Principles
u   Treatment meets standard of care
u   Treatment is individualized
    • initial , ongoing, & collateral assessment
    • not laissez-faire treatment: organized and planful
    • ongoing review/adjustment of treatment plan
u   Client empowerment/colloboration
    • client engagement in the process, with responsibility for
    • client consulted on/understands treatment plan
    • posttraumatic treatment philosophy and techniques
          Treatment Principles
u   Safety and protection
    • Safety of self and others, to and from others
u   Relationship issues
    • Boundaries, limitations, respect
    • Responsibilities of the therapist
       – trustworthy/non-exploitive
       – relationship as container
u   Informed consent/refusal; client rights
    • professional privilege/limits of confidentiality
    • right to seek consultation/2nd opinion
    • rights to refuse and terminate treatment

  Variable Adaptations

Variable and Multi-modal
   Complex Trauma Treatment
• Specialized techniques, applied later
   – EMDR for resource installation/affect mgt,
     CBT (exposure therapies), CPT, stress
• Other techniques as needed (careful
   – relaxation, exercise, group, education,
• Couple or family work
     Complex Trauma Treatment
u   PTSD symptoms
u   Depression, anxiety, & dissociation
u   Problems with affect regulation
    • may rely on maladaptive behaviors, substances
    • problems with safety
u   Negative self-concept
u   Problems with self, attachment,relationships
    • revictimization/re-enactments
    • needy but mistrustful
u   Problems functioning?
u   Physical/medical concerns
u   Other...
    Complex Trauma Treatment
u   “Not trauma alone” (Gold, 2000)
u   Multi-theoretical and multi-systemic
u   Integrative
u   Addresses attachment/relationship issues in
    addition to life issues and trauma symptoms
    and processing of traumatic material
          Treatment Sequence
u   Safety, stabilization, skill-building
u   Trauma processing
u   Integration and meaning, self and
    relational development
       Treatment Sequence:
    General Stages of Treatment
u   Pre-treatment stage: Contracting, assessment, pre-
    treatment issues
u   Early stage: Safety, stabilization, skill-building,
    self-management, security in tx relationship
u   Middle stage: Trauma de-conditioning,
    processing, mourning, resolution, moving on
u   Late stage: Self and relational development from a
    new perspective
Note: Non-linear and not lockstep: a back and forth, titrated process
  with attention to and planning for relapse
     Treatment: Chronic PTSD
u   May be delayed/chronic
    • Longer term treatment (ongoing or episodic)
       – comorbidity/dual dx
    • Psychopharmacology
    • Stabilization, skills training, crisis management, safety,
      affect regulation, life skills, self-care
    • Specialized techniques, applied later
       – EMDR for resource installation/affect mgt, CBT
         (exposure therapies), CPT, guided imagery &
         energy & somatosensory techniques, stress
    • Other techniques as needed (careful application)
       – relaxation, exercise, group, education, wellness,
         couples or family work, etc.
    Treatment: Chronic/Complex PTSD
u   Ongoing assessment
u   Longer term treatment (ongoing or episodic)
    • comorbidity/dual dx/co-ocurring dx
u   Sequenced treatment
    • more initial emphasis on stabilization, self-
      management, affect regulation, safety, relapse planning
u   Psychopharmacology
u   Specialized techniques, applied later
    • EMDR starting w/ resource installation/affect mgt,
      CBT (graduated and/or direct exposure), CPT, stress
      inoculation, relaxation, hypnosis, group, education,
      wellness, couple‟s or family work
    “Hybrid” Models for Complex Trauma

u   TARGET (Ford)
u   STAIR-NTP (Cloitre)
u   Seeking Safety (Najavits)
u   ATRIUM (Miller)
u   SAFE Alternatives (Conterio & Lader)
u   Others...
  Like Posttraumatic Disorders,
  comprehensive treatment must be
Culture and Gender Sensitive
Bio/Physiological Treatments
• Psychopharmacology
  – evidence base developing re: effectiveness
  – algorithms developed
  – not enough by itself
• Medical attention
   – preventive
   – treatment
• Movement therapy
     Bio/Physiological Treatments
u   Stress management
u   Self-care/wellness:
    •   Exercise (w/ care)
    •   Nutrition
    •   Sleep
    •   Hypnosis/meditation/mindfulness
    •   Addiction treatment
         – Alcohol, drugs, prescription drugs
         – Smoking cessation
         – Other addictions (sexual, spending)
         – Relapse planning
     Bio-physiological Treatments
u   Somatosensory/Body-focused Techniques
                        (Levine; Ogden; Rothschild, Scaer)
    Remember: The brain is part of the body!
n   Paying attention to the body in the room
    • interpersonal neurobiology
n   Neurofeedback/EEG Spectrum
n   Massage and movement therapy
n   Dance and theatre
n   Yoga
Psychosocial/Spiritual Treatments

u   The therapy relationship--has the most
    empirical support of any “technique”
u   Especially important with the traumatized
u   Especially important in interpersonal
    violence and in developmental trauma
    • attachment studies
    • brain development studies
    • striving for secure attachment
Psychosocial/Spiritual Treatments
u   Psych-education (individual or in group)
u   individual and group therapy
    •   trauma focus vs. present focus
    •   skill-building
    •   core affect and cognitive processing
    •   developing connection with others
         – identification and meaning-making
    • concurrent addiction/ED
u   couple and family therapy
Psychosocial/Spiritual Treatments
u   adjunctive groups/services
    •   AA, Al-Anon, ACA, ACOA, etc.
    •   Social services/rehabilitation
    •   Career services
    •   Internet support and information
u   spiritual resources: finding meaning in suffering
    •   Pastoral and spiritual care
    •   Organized religion
    •   Other religion/spirituality
    •   Nature, animals
 Cognitive Behavioral, Emotional/
Information Processing Treatments
n   Education & skill development
    u   numerous workbooks now available on a wide
        variety of topics
         F   general, CD, self-harm, risk-taking, eating,
             dissociation, spirituality, career, etc.
n   Exposure and desensitization (Foa et al.)
    u   prolonged & graduated
n   Writing/journaling
    u   CPT (Resick)
    u   Journaling (Pennebaker)
 Cognitive Behavioral, Emotional/
Information Processing Treatments
n   Schema therapy (Young; McCann & Pearlman)
n   DBT (may involve “tough love stance”) (Linehan)
    u   mindfulness and skill-building
n   Narrative therapies (various authors)
n   Strength/resilience development
    u   EMDR resource installation (Leeds & Korn)
         Developmental Needs Meeting Strategy (Schmidt)

    u Internal Family System work (Schwartz)
    u Solution-focused treatment (O‟Hanlon)
         Cognitive Behavioral and
    Information-Processing Treatments
n   EFTT: emotion-focused therapy for trauma
n   ACT: acceptance and commitment therapy
                               (Hayes, others)
n   FAT/FECT: Functional Analytic Therapy
                               (Tsai, Kohlenberg)
n   IRRT: imaginary re-scripting and re-
    processing therapy       (Smucker)
n   Virtual Reality          (Rothbaum, others)
          Affect-Based Treatments
n   AEDP: Accelerated Experiential-Dynamic
    Psychotherapy                   (Fosha)
n   Affect Experiencing-Attachment Theory
    Approach                     (Neborsky)
n   Healing the Incest Wound
                          (Courtois; Roth & Batson)
n   Repair of the Self              (Schore, others)
n   Techniques for identifying and treating
    dissociation (ISSD, Kluft, Putnam, Ross, others)
n   Relational and affect-based psychoanalytic
    techniques (Bromberg, Davies & Frawley, Chefetz,
                Core Affects
u   Fear/terror
u   Anxiety
u   Depression
u   Anger/rage/outrage
u   Shame
u   Self-blame/guilt
u   Confusion
u   Grief/mourning/sadness
u   Alienation
u   Other…
Relational/Attachment Treatments

u   Understand client‟s attachment style and
    Inner Working Model
    • Helps expect how the client relates and behaves
u   Strategize how to respond
u   Goal: to move to secure attachment through
    insights gained in and through the therapy
    Relational/Attachment Techniques
n   Interpersonal neurobiology (Schore, Siegel)
n   Relational and affect-based psychoanalytic tx
n   Patient in relationship with others
     u   determine attachment style
     u   Therapist
          u   determine attachment style
          F   secure connection with the therapist to foster secure
              connections elsewhere (“earned security”)
          F   transference/countertransference, enactments, VT
     u   Spouse/partner/significant other
          u   couple and family work
Relational/Attachment Techniques
n   Hypnosis or EMDR-based internalization of
    attachment          (Brown; Leeds & Korn; Omaha)
n   Children
    u   parenting help/training
n   Friends
    u   substitute family
    u   social and friendship skills
n   Support systems
n   Work colleagues
         Note: Various workbooks and community
         training programs available for these
Hypnosis/Guided Imagery Techniques
Caution: for ego development, self-soothing,
  attachment, not for memory retrieval
n Hypnosis
    u   Brown & Fromm; Brown
    u   Dolan
    u   Phillips & Frederick
    u   Kluft
    u   Schwarz
n   Guided Imagery
    u   Naparstek
           Expressive Techniques

n   Art
    u   collage
    u   images
    u   pottery/clay work
n   Poetry/writing
n   Psychodrama
n   Movement
n   Nature
n   Specific spiritual writers and orientations
n   The meaning of suffering
n   Existential issues
n   Religion
n   Pastoral care/spiritual issues
n   Prayer
n   Spiritual formation
u   Social context/ethnic group and how it
    might contributes to trauma
       – racism, sexism, heterosexism and homophobia,
         cultural or ethnic norms, colonialism, etc.
u   Blocks or supports to healing
u   Take these issues into account
u   Healing rituals
u   Healers
Treatment: Chronic/Complex PTSD
u   Some never fully recover from symptoms
    even after many years/intensive treatment
    • those w/ history of childhood abuse/trauma
      and other risk factors
u   The absence of symptoms does not mean
    that the disorder has run its course
    • patterns of cyclical decompensation have been
u   Treatment is applied according to the phase
    of the decompensation cycle
u   Trauma studies have increased information
    and understanding
    • Trauma can vary dramatically, as can responses
    • New conceptual and diagnostic models account
      for variability
u   Treatment
    • Is multimodal
    • Is bio-psycho-social
    • Must be individualized
       – type of trauma response/disorder
       – individual needs
    • Has some empirical support…more to come!
u name; formerly (
     • 9 month-long courses on the treatment of DD‟s-
       -various locations
u (info and links)
u (child resources)
u (books and tapes)
u   APA Division 56, Psychological Trauma
u please join!!
The Rewards of the Work

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