Complex Psychological Trauma

The Centrality of Relationship

Philip J. Kinsler

• Publisher: Routledge
• Year: 2017
• ISBN:
  9781317311461
• Edition: 1
• Topic: Psychologie
• Subtopic: Posttraumatische Belastungsstörung (PTBS)

Complex Psychological Trauma takes clinicians beyond the standard approaches for treating simple, single-stressor incident PTSD. Here the focus is on the major choice points that establish the relational conditions for growth and change. In these pages, new and experienced clinicians alike will find specific guidance for acting in a relationally healing manner and refreshingly practical, real-life advice on what to say in challenging therapy situations.

PART I
CORE QUESTIONS AND CONCEPTS

1
INTRODUCTION

This book is written for three purposes. The first is to set the stage, explain basic concepts, and discuss questions the book is meant to answer.

The second is to discuss diagnostic thinking—what concepts are important in trying to understand the client before us? That section of the book presents an integrationist view of diagnosis. Theories are lenses and use of all available lenses, from the biological to the psychosocial, can increase our understanding of clients and improve our abilities to match our techniques to the client.

The third section of the book follows three complex trauma cases through the process of therapy relationship formation, and the actual therapy relationship management work. That section focuses specifically on how to form productive relationships with persons with various experiences of attachment to other human beings. The literature calls these “attachment stances.” The book stresses the relationship with the therapist as one of the most central predictors of therapeutic success. I have previously called this “the centrality of relationship” (P. J. Kinsler, 1992, 2014; P. J. Kinsler, Courtois, & Frankel, 2009).

What Is Psychological Trauma?

“Trauma” is a word that has been tossed around so frequently that it bears discussing and defining. There are two approaches to what constitutes a “trauma,” the objective and the experiential. A trauma is a psychologically overwhelming experience. It is so overwhelming that typical human information processing is interrupted. This is not the portion of the book to describe that in detail; it is discussed later. But, in brief, let’s say something emotional but not overwhelming happens to a person—perhaps we get critical feedback on a paper. Our sense organs perceive what has happened; in this case, we read the feedback, and pass this on to other portions of the brain.

In the most simplistic but useful level of analysis, the brain has three different operations centers. Our so-called reptilian brain, the brain stem, and related organs do things such as regulate our heart rate and breathing automatically so we do not have to consciously think 70 times a minute, “Oh, better contract my heart.” In the “critical feedback” example, maybe these portions of our brain up our heart rate and breathing some, because this is what they do when we experience stress.

The second operating system consists of what is called the “limbic system”—those portions of the brain that feel and process fear and other emotions, and that look in our database of prior experience for context. “Hmmm, this is sad and somewhat deflating. Have I seen this before? Where?”

The third operations center is our cortex, which thinks over and makes sense of experience: “Oh, we’ve gotten this kind of feedback before… what did we do? OK, we really did not do our best on that paper… something to learn there… also, the professor said we did not clearly define certain concepts… can go back and look at that. Maybe I didn’t get what she/he meant about trauma. I could ask a question in class… or I could go and talk to her/him… think I’ll do that.”

A human/interpersonal component is also used to process and resolve the event. This is essentially the question of whether we have been soothed in a way that calms the emotion centers. So, in our poor paper example, we talk to another student. They tell us the professor is a stickler, but one learns from her/him. They know you’re smart enough to do a good re-write. They believe in you; they’ve seen you grow from, and get through, this kind of thing before. As this happens, your breathing starts to slow, your heart rate comes down, likely there’s a large, cleansing exhale, you begin to relax and feel OK about yourself again.

What we see here is a process of getting soothed, conceptualizing, making sense of, planning to take control over, and deciding on action steps. This processing has an effect back on the emotion centers. It leads to a felt sense that we have managed the event, come to terms with it; it does not need much further intellectual or emotional work. It feels “resolved” or “mostly resolved.”

Psychological trauma interrupts and interferes with these normal stages of event processing. The limbic system goes into fear overdrive. This interferes with connections between the limbic system and the cortex. In effect, our abilities to make sense of, work over, and put away our reactions to the experience are interrupted, and we are left with raw emotion. If there is no soothing, our abilities to calm and re-regulate our physiological reactions are interfered with, as is our sense-making ability. And so, we develop a set of typical reactions to manage this unresolved material (M. Cloitre et al., 2009; van der Kolk, 1996, 2002, 2005, 2014).

These reactions typically come in four areas: intrusive thoughts about the event, efforts to avoid feelings about the event (numbing), hyper-vigilance to stimuli possibly similar to the event (e.g., startle reactions), and changes to our sense of self.

Let’s use the “simple” example of a car accident in which your leg is broken but you survive. No one particularly takes care of you. “It’s only a broken leg.” “Stop making such a big deal.” No one soothes the fear, the feeling you might have been killed, the pain of the leg, or the change in your sense of safety. You might then come away with fears of driving, visions of the accident, hyper-anxiety when you attempt to drive, and a permanently changed sense of how safe you are in the world. If you’re the self-blaming type—and this book discusses later in considerable detail how this often helps a child process trauma—you might even come away feeling, “I’m an idiot, I should have looked more carefully. I was going 5 mph over the limit. I could have killed someone. I’m a much more awful person than I thought I was before the accident.” Thus, we develop all four clusters of what we have come to term posttraumatic stress disorder (PTSD) (American Psychiatric Association, 2000, 2013; van der Kolk, 2014).¹

What About That Distinction Between Objective and Experiential Trauma?

People react differently to events. Some of this is undoubtedly temperament. Other causes of variability come from whether we have safe and soothing experiences as an infant, and also later in child development (J. Bowlby, 1980, 1983, 1988, 1989; Winnicott, 1958, 1965, 1969). For some persons, relatively mild events from the standpoint of other persons may feel traumatic. For example, it takes the therapist an hour to return an emergency call. Other persons do not experience the emotional overwhelm and frozen fear of trauma despite actual combat experiences.

As a field, we struggle with this phenomenon, and not very well. Our struggles are represented by changes in what we define as Criterion A in our diagnostic manuals for PTSD (American Psychiatric Association, 2000, 2013). We struggle to say what should or should not be considered traumatic. For this book, the content of any particular formation of specific criteria sets is less important than our recognizing the human variability in what feels traumatic, and understanding why, to the person in front of us now, with their history and genetics, the events they are discussing feel like trauma. With certain clients, we, of course, have the task of helping them redefine and re-conceptualize that disappointments or stubbed toes are not typically seen as trauma. But we must also understand how in their inner world, the sense of such events as traumatic came to be. We strive to balance the objective with the phenomenological.

What Is Complex Trauma?

Many persons experience multiple traumas, sometimes over long time periods, and of many different types. It is not unusual for a child to experience physical abuse, neglect, verbal abuse, parental substance abuse and incarceration, and communal/gang violence, over the course of years. This creates the phenomenon of complex trauma, sometimes also called “polyvictimization” (Boxer & Terranova, 2008; Bradley, Jenei, & Westen, 2005; Carlson et al., 2001; C. A. Courtois, 2012; English, Graham, Litrownik, Everson, & Bangdiwala, 2005; D. Finkelhor, Ormrod, & Turner, 2007; D. Finkelhor, Ormrod, Turner, & Hamby, 2005; Ford, Elhai, Connor, & Frueh, 2010; Ford, Grasso, Hawke, & Chapman, 2013; Hamby, Finkelhor, Turner, & Ormrod, 2010; Herrenkohl & Herrenkohl, 2007; Higgins & McCabe, 2001; Holt, Finkelhor, & Kantor, 2007; Renner & Slack, 2006; Smith, McCart, & Saunders, 2008; Turner, Finkelhor, Hamby, & Shattuck, 2013; Turner, Finkelhor, & Ormrod, 2010; van der Kolk, 2007).

How Is Complex Trauma Different From Single-Event Trauma?

The more types of trauma a person experiences, the greater the effect on the survivor. A dose-response relationship exists between the number and variety of types of trauma experienced, and later psychological and physiological/health effects. (Felitti, 1998) Trauma over the course of a childhood affects the growing child’s entire sense of him/herself, and of the world around them. “Are people safe? Am I worth loving? Can I ever relax without danger sneaking up on me? I must have brought this on. If only I were better this would not happen. I better learn how to please the people abusing me. Close feelings only result in abuse and rape.”

Human beings are sense-makers. We try to find a way to make sense of the world and ourselves, even in the face of the worst horror (Frankl, 1997). Complex trauma affects everything: how we think, how we feel, how we relate to others, how we relate to ourselves.

Complex trauma also affects physiological unfolding and development (Figueroa & Silk, 1997; Porges, 2001; A. N. Schore, 1994, 1996, 1997, 1998a, 1998b, 2000a, 2000b, 2001a; Strathearn, 2007). This topic, often called epigenetics, occupies entire volumes of learned literature. For this book, it is enough to say that complex abuse experiences influence the physiological development of brain systems involved in threat evaluation, sense of self, establishment and maintenance of social and love relationships, and regulation of upset—our entire emotion regulation system. Effects of complex trauma are substantial and global across child development.

Although researchers have often focused on one or another type of victimization—physical abuse, exposure to domestic violence, sexual abuse, etc—the natural history of our clients shows exposures to many types of violence/abuse within their families. A study published in June 2015, as this book was being written, used data from the National Survey of Children’s Exposure to Violence. Results showed that:

It was common for children and youth to be exposed to multiple types of episodes over the course of a year. In total, 40.9% had more than 1 direct experience of violence, crime, or abuse, 10.1% had 6 or more, and 1.2% had 10 or more. Overall, 60.8% of the children had at least 1 form of direct exposure in the last year. When witnessing and indirect exposures were combined with direct exposure, 67.5% of the children had at least 1 exposure, 50% had more than 1 exposure, 15.0% had 6 or more exposures, and 4.4% had 10 or more exposures.

Furthermore:

… experiencing one type increased the likelihood of experiencing other types as well. For example, having a past year physical assault was associated with a 4.9 times higher likelihood of experiencing a sexual offense and a 3.4 times higher likelihood of caregiver maltreatment… every combination had a significant risk amplification.

(D. Finkelhor, Turner, Shattuck, & Hamby, 2015)

Not quite tongue in cheek, I have previously written that the clients who come for long-term trauma therapy are survivors of “horrible life disorder” (P. J. Kinsler & Saxman, 2007). For some reason, I’ve had trouble getting this into the DSM.

The data above are not from clinical cases, but from a national epidemiological sample. And 20% of non-clinically selected children experience multiple types of victimization over a single calendar year! Lives such as these predispose to physical health (Felitti, 1998) and general psychiatric issues, depression, substance abuse, and juvenile justice involvement (Elhai et al., 2012; Ford et al., 2010; Spinazzola et al., 2005).

Do We Need Special Methods to Treat Complex Trauma?

Perhaps there are clinicians who can effectively deal with complex trauma using only manualized therapies and exposure treatments. This book will not resolve those arguments. My experiences, and those of multitudes of therapists and clients, show that very often much more is needed. As I and other highly valued colleagues have stated before:

Child abuse and attachment failures are relational events and experiences, occurring most often within families, between parents and children. The consequences profoundly affect the child’s physiological/biological and psychological development, and ability to form close and trusting relationships. Victimized children are hurt in relationships, yet, paradoxically, relationships can be the core component of healing from these injuries. At times, special relationships such as close friendships, mentorships, marriages, partnerships and, in some cases, parenting of one’s own children, can be restorative when they provide the attachment security the individual needs to learn new ways of relating [to] and trusting others. Psychotherapy may also provide the needed “safe haven” within which to modify old relational patterns that were built on insecurity and exploitation. Stated simply, whether it occurs within or outside of psychotherapy, healing of complex and chronic trauma associated with abuse (especially when there is a foundation of attachment trauma) occurs in safe, dependable, kind, and bounded relationships.

(P. J. Kinsler et al., 2009, p. 183)

What Are These Attachment Stances Anyway? Why Are They Important?

Attachment theory is presented in far greater detail later. For those without a basic introduction, let’s start out with the fact that the human infant is entirely dependent on others for safety and survival at birth, and for very lengthy times thereafter. And never forget that infants have global/whole person experiences (Main, Kaplan, & Cassidy, 1985). Who has not experienced a fussy infant going instantly to joy when cuddled right, or distracted by a toy, or tossed in the air and caught by grandpa or grandma? Infants depend on adults for soothing and safety, which they are not developmentally or physically capable of providing for themselves. When the infant-to-toddler is effectively responded to often enough when they are emotionally dysregulated—when they experience “good enough mothering”—they develop an internal felt sense that they are safe in the world, and that there are secure and dependable sources of calming out there (J. Bowlby, 1988; Main, 1995, 2000; Main, Hesse, & Kaplan, 2005; Winnicott, 1957a, 1957b, 1958). We call this secure attachment. It produces children with the general sense that the environment is primarily trustable and that they are also people worthy of care and safety.

What if the relationships are not so safe, stable, and predictable? There are then three main ways of forming an overarching sense (schema) about self and world. Two kinds of insecure attachments can form. In one case, the baby/toddler experiences inconsistent soothing and becomes ambivalent; they want and need safety and contact, but are afraid it will be taken away. So, they fearfully cling. This is called insecure/ambivalent, or, in some writings, insecure/preoccupied. The child is clingy and preoccupied with the fear of loss. Strike any parallels with many clients’ dependent behaviors?

Other children may yearn for connection, but firmly believe it will never be out there. So, they develop armor. “I don’t need anything, I won’t lean on anyone; you can’t hurt me if I don’t let you in.” The fancy term for this is insecure/resistant. Sometimes, our adult “over-functioners” come from this stance. Other times, just our social isolates.

Finally, what if nothing the child does leads to any predictable reaction from the caretakers? One minute safety; another horrid abuse; a third, shame-filled apologies, yet another, physical attack. Nowhere to turn. No home base. No safety. Danger all around. A risk of overwhelming anxiety all around. The feeling of an enc...