Diagnosing and Treating Complex Trauma

Trudy Mooren, Martijn Stöfsel

• Publisher: Routledge
• Year: 2014
• eBook ISBN: 9781317700562
• Topic: Psicología
• Subtopic: Salud mental en psicología

The term complex trauma refers to a broad range of symptoms resulting from exposure to prolonged or repeated severely traumatizing events. This broad spectrum of psychological symptoms complicates the formulation of an all-encompassing explicit definition, which in turn complicates the creation of specific treatment guidelines. In Diagnosing and Treating Complex Trauma, Trudy Mooren and Martijn Stöfsel explore the concept of complex trauma with reference to severely traumatised people including refugees, asylum seekers, war veterans, people with severe occupational trauma and childhood trauma and others who have dealt with severe violence.

The book introduces a layered model for diagnosing and treating complex trauma in four parts. Part One introduces the concept of complex trauma, its historical development and the various theories about trauma. The authors introduce a layered model that describes the symptoms of complex trauma, and conclude with a discussion on the three-phase model. Part Two describes the diagnostic options available that make use of a layered model of complex trauma. Part Three discusses the treatment of complex trauma using the three-phase model as an umbrella model that encompasses the entire treatment. Chapters cover a multitude of stabilization techniques crucial to the treatment of every client group regardless of the therapeutic expectations. This part also contains an overview of the general and specific trauma processing techniques. The last chapter in this part covers the third phase of the treatment: integration. Part Four addresses the characteristics of different groups of clients who are affected by complex trauma, the components that affect their treatment and the suggested qualities required of a therapist to deal with each group. The book concludes with a chapter discussing the consequences for therapists providing treatment to people afflicted by complex trauma.

Developed from the authors' own clinical experiences, Diagnosing and Treating Complex Trauma is a key guide and reference for healthcare professionals working with severely traumatised adults, including psychologists, psychotherapists, psychiatrists, social-psychiatric nurses, and case managers.

Part I
Definition and treatment models

Chapter 1
Complex trauma defined

Complex trauma is a term commonly used to describe the problems of severely traumatized people. The concept, however, has not been properly defined, yet no other term adequately covers all the problems that typically result from multiple interpersonal events of violence (Chu, 2011; Courtois & Ford, 2013). The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) (American Psychiatric Association, 2000), for instance, refers to posttraumatic stress disorder (PTSD), but its diagnostic criteria fail to adequately describe the effects of experiencing multiple repeated traumatizations. The new edition (DSM-5; APA, 2013) encompasses an additional category to describe negative alterations in cognitions and mood but is far from complete in describing the more complex symptoms observed in most severe clients. The World Health Organisation (WHO) while preparing the International Classification of Diseases (ICD-11) suggests including both PTSD and complex PTSD as describers of trauma-related features (Cloitre et al., 2013). Thus, for want of a better word, in this book we will use the term ‘complex trauma’ to cover the full spectrum of reactions and symptoms resulting from exposure to multiple or repeated traumatic childhood or adulthood events and including both the shocking events themselves and their psychological and social repercussions.

Although most people manage to cope with the effects of complex trauma and carry on with their lives as normal, some people experience complex traumatizations and develop severe problems, which, as mentioned above, we will refer to as complex trauma. This introductory chapter explores the concept of complex trauma.

1.1. Disruptive experiences

This section discusses a few typical features of the events that precede the development of complex trauma.

1.1.1. Chronic and multiple exposure

People who suffer from complex trauma have been exposed to prolonged, multiple events of a violent nature. Examples are incest, sexual abuse, maltreatment, torture, captivity, and war. In some cases people with complex trauma have been exposed to extremely severe forms of violence and terror, such as witnessing the torture or death of another person.

In the 1970s, a South American man was picked up by the military police of his country, tortured and severely maltreated. Among other things, the police hung him by his arms tied behind his back, administered electrical shocks to his body and extinguished cigarette butts on his back; the man was even raped on one occasion. Held in captivity for 18 months under extremely adverse conditions, he witnessed how cellmates who had been physically tortured ultimately succumbed to their injuries.

After seeking refuge in the Netherlands, he married, had children, and seemed to be coping well. In recent years, however, most especially as his children have gradually left home, he has been suffering from intrusive images and nightmares about events of the past and is now seeking help.

1.1.2. Interpersonal violence

Sexual abuse, physical abuse, torture, captivity, and domestic violence are examples of severe violence inflicted on people by other people. Such interpersonal violence has a greater negative impact than violence caused by nature. Violent acts of nature are experienced as a whim of fate or as caused by a higher power because they are not preceded by conscious human acts. Interpersonal violence, however, always leads to slight to severe mistrust of others.

A Bosnian woman raised in a family atmosphere of affective neglect fled with her family from Serbian violence during the Balkan War. After two men from the family that sheltered them raped her, she sought help from a therapist for PTSD. During the consultation, she was observed not to be forthcoming but to be rather detached and reticent.

1.1.3. Limited (or no) support

Most victims of complex trauma have, at best, a limited support system available to them during or after a traumatic event, mainly due to the severe disruption caused by a war and the quantity of people who have had to flee or emigrate. This leaves little, if any, support for people who are severely victimized, as people, in general, are operating in survival mode.

Victims of incest, sexual abuse, physical abuse, and domestic violence often do not seek support because the perpetrators are known to them or they may be bound by feelings of loyalty. Families in these situations tend to socially distance themselves and frequently limit their reaction to the maltreatment by coping in fearful silence while secretly bearing the weight of this knowledge.

Soldiers at war often have experiences that are so alienating and shocking that they are unable to talk about them after returning home, with family and friends simply failing to understand what they have been through. The alienation experienced during deployment thus often continues after they return home.

A man who had served in Lebanon for years sought help because of feelings of social isolation that led to his marriage ending in divorce. For years he had felt that his wife did not understand him and he had never dared to tell her about his traumatic experiences, such as seeing a ten-year-old boy shot right in front of him as they were talking to each other and seeing people burning alive while trapped inside a jeep that was struck by a missile. He had also felt powerless using outdated equipment to carry out what he perceived to be an impossible mission: establish peace, but do not intervene.

1.1.4. Differing impact depending on life stage

A person’s development will be influenced differently depending on the life stage when the overwhelming events take place. A distinction can be drawn between three broad exposure groups, depending on the period over which a person is exposed to trauma.

1.1.5. Childhood exposure

People in this group undergo overwhelming events early in life that have a strong negative effect on their development of stress sensitivity, personality, identity, and autonomy. Such events, which often involve maltreatment and sexual abuse, are accompanied by personality disorders, including dissociative disorders (Van der Hart et al., 2006). Also belonging to this category is the post-war generation of children who grow up in the shadow of a conflict, raised by at least one parent who had directly experienced a war. The experience of war often damages parenting ability, leaving children in eventual need of help. Families in these circumstances commonly show a great deal of stress, a lack of intimacy and warmth, and high levels of anxiety.

1.1.6. Adult exposure

This group of clients had a stable childhood, but has since witnessed traumatic events. Examples are war veterans and most refugees. War veterans are usually young adults aged between 18 and 20 years at the time of their first mission. Many refugees from war-stricken countries are also in this category. The traumatic experiences of refugees in their country of origin are further exacerbated by stressful experiences in their host country.

1.1.7. Childhood and adult exposure

People who have experienced domestic violence, maltreatment, or sexual abuse as children usually develop a vulnerable personality structure and are at greater risk of developing a psychological disorder if exposed to a shocking event later in life. Negative early childhood experiences have been shown to be a strong predictor of the severity of PTSD symptoms that may develop later in life.

1.2. History of complex trauma

Clinicians and scientists have long been concerned with the effects of violence and shocking events on the human mind. Important historical events and social movements, moreover, have affected how they view the effects of severely overwhelming experiences. Historical events that gained the attention of scientists were full-scale wars such as the American Civil War, the First World War, the Second World War (including the Holocaust), the Vietnam War, the Balkan Wars, and the recent conflicts in Iraq and Afghanistan. As for social movements, these include the women’s movement, migration flows, and changing attitudes to children’s rights. Even though shocking events have led to violence and the disruption of life since time immemorial, relatively speaking, scientific research on the effects of such disruptive life events is still in its nascence.

1.2.1. A brief history of PTSD

Different terms were used in the nineteenth century to describe severe physical and emotional reactions resulting from overwhelming events; for instance, railway spine was the diagnosis for symptoms occurring after a train accident, and traumatic neurosis referred to injuries to the head (Kleber & Brom, 1992). Originally the physical damage was thought to cause the symptoms, but Pierre Janet was the first to point to the psychological processes that were at work after the event. Van der Hart et al. (2000), who thoroughly reviewed Janet’s work, describe the processes of dissociation, memory fragmentation, and emotional fragmentation. The assumption was that traumatic experiences fragmented one’s consciousness, with the detachment of overwhelming emotions from consciousness serving as a coping mechanism that enabled the person to continue functioning. The therapeutic processing of deeply overwhelming experiences included the reintegration of unprocessed traumatic memories with normal consciousness.

The First World War confronted society with the severely emotionally and physically damaged soldiers who had suffered the horrors of the trenches. Their complaints were ascribed to shellshock, the term used to initially describe the physical damage caused by explosions, bombardments, and shrapnel. Gradually, however, psychological explanations for the intense emotional problems experienced by soldiers began to take form. Pat Barker’s Regeneration trilogy (1991), about the work of the psychiatrist Dr William Rivers and his colleagues, is illustrative of how trauma was conceptualized during the First World War (Shepard, 2000).

The Second World War confronted the world with such extreme horrors that new terms – such as concentration camp syndrome, survivor syndrome, and KZ syndrome (where the KZ refers to Konzentrationslager) – were coined to describe the consequences for psychological functioning caused by these traumas (Enning, 2009; Jongedijk et al., 1995). Soldiers experiencing traumatic reactions after the Second World War were considered to be suffering from combat fatigue, with terms such as traumatic neurosis, gross stress reaction, and adjustment reaction commonly used by the general public (Kleber & Brom, 1992). This was the first time the link between overwhelming experiences and stress was made.

In his exposition titled Stress Response Syndromes: PTSD, Grief and Adjustment Disorders, Horowitz (1997) makes explicit use of the new stress paradigm. Horowitz’s fundamental notion is that traumatized persons experience more stress than they can cope with or think they can cope with, calling this an issue of appraisal. Two fundamental tendencies help to normalize the overburden of stress, namely, reexperiencing and avoidance. Although notions regarding an individual’s capacity for resilience and endurance (stimulus barriers) had been addressed by Freud, they have recently gained new momentum because of the meaningfulness of the cognitive component included by Horowitz.

Dutch authors (Bastiaans, 1974; Blijham, 1984; Cohen, 1969; Hustinx, 1973; Musaph, 1973) have regularly addressed stress reactions in Holocaust survivors and in other groups of war-stricken people using various terms such as KZ syndrome, concentration camp syndrome and existential emotional stress syndrome while emphasizing the existential dimension of the violence. This dimension particularly affects a person’s ability to enter into and maintain relationships, and to give meaning to the violent events and to life in general; survivors also experience survivor’s guilt, which is guilt associated with surviving when others died.

The historical event that very well may have had the greatest bearing on defining PTSD as we know it today was the Vietnam soldiers’ homecoming to the USA. In retrospect, recovery was not so much a matter of dealing with what happened there during the war and its consequences but of facing up to the growing lack of social support at home for returning servicemen and servicewomen. By the end of the 1960s, US society was completely opposed to the deployment of soldiers to Vietnam, and returning soldiers could not count on much support; at times they were even publicly shamed.

PTSD, however, would have never been included in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) had it not been for the pressure exerted by the women’s movement in general, including feminists, who demanded that victims of sexual violence and abuse – often young – be given the attention they needed (Herman, 1992).

1.2.2. PTSD

PTSD (Appendix 1) has carved out a place of its own in the DSM since the publication of DSM-III in 1980. It is the only diagnosis to have situational circumstances included as a criterion (that is, the criterion is external to the person). This has led to tremendous debate regarding the definition of and criteria for PTSD in subsequent versions of the DSM, as it is very difficult to reach consensus on which severe symptoms – reexperiencing the trauma, avoidance behaviour, and the hypervigilance – are required for a diagnosis of PTSD (APA, 2000).

A diagnosis of PTSD is only made when the traumatic events are intrusive or reexperienced, when the associated stimuli are persistently avoided, and when there are symptoms of increased arousal (hyperarousal or hypervigilance) that were not present prior to the event. Examples of in...

Table of contents

• Cover
• Title
• Copyright
• Contents
• Preface
• PART I Definition and treatment models
• PART II Diagnostics and indication assessment
• PART III Treatments
• PART IV Client and therapist
• Appendices
• References
• Index