Complex Trauma

The Tavistock Model

Joanne Stubley, Linda Young, Joanne Stubley, Linda Young

• Publisher: Routledge
• Year: 2021
• ISBN:
  9781000476354
• Edition: 1
• Topic: Psychologie
• Subtopic: Posttraumatische Belastungsstörung (PTBS)

The new diagnosis of Complex Post Traumatic Stress Disorder presents diagnostic and treatment challenges that need to be grappled with, since, in a troubled world, it is increasingly important to understand the impact and aftermath of traumatic experiences and, crucially, how to work with those affected by them.

In Complex Trauma, Joanne Stubley and Linda Young have assembled a fascinating range of approaches in order to explore the questions of understanding and intervention. They detail the relevance of an applied psychoanalytic approach, both in the Tavistock Trauma Service and, more broadly, in illuminating understanding of traumatized individuals. The book includes chapters related to the impact of trauma on the body, as well as on the mind, incorporating neurobiological and attachment theory to develop ideas on the impact and aftermath of complex trauma. A number of specialist areas of trauma work are covered within this volume, including work with adolescents, with refugees and asylum seekers, with military veterans, and with survivors of child sexual abuse.

The editors bring together chapters that will be of interest to those working with traumatized individuals in a variety of settings and using different modalities. The central importance of relationships, as understood within the psychoanalytic model, is depicted throughout as being at the heart of understanding and working with traumatic experience.

PART I

THE CLINICAL WORK

CHAPTER ONE

Complex trauma: the initial consultation

Joanne Stubley

DOI: 10.4324/9781003227182-3

Trauma is a commonplace word found in everyday vocabulary as well as in the more specialized fields of psychology, psychiatry, and psychoanalysis. Yet the definition of what constitutes a trauma and the understanding of its impact on a particular individual varies widely. Sigmund Freud originally described trauma as a breach in the protective shield around the mind, a shield that prevented the mind from being overwhelmed by stimuli. The emphasis for Freud was on an experience of helplessness (Freud, 1920g).

Van der Kolk, McFarlane, and Weisaeth (1996) describe trauma as an inescapable event that overwhelms existing defences, and Judith Herman (1992b) focuses on the experience of being rendered helpless. While each definition has its own particular emphasis, all stress the inescapable, overwhelming helplessness with usual defences rent asunder.

While there are many possible outcomes that may occur following a traumatic event, including the significant possibility of posttraumatic growth, for many clinicians working within mental health the most common presentation will be posttraumatic stress disorder (PTSD).

The diagnosis of PTSD has been in common usage since the mid-1980s; originally used to describe the experiences of Vietnam veterans in the United States. The symptoms that typically occur are re-experiencing symptoms of nightmares, flashbacks, intrusive thoughts and images, and triggers for these symptoms, such as intense physiological distress; avoidance and numbing symptoms, which includes avoidance of anything associated with the event, alongside an emotional blunting and shutting down; and hyper-arousal symptoms, with hyper-vigilance and exaggerated startle response. There can be a lowering of mood and a distortion of thoughts, as may be seen in depression—feeling low, feeling one’s future is fore-shortened, having negative thoughts about the world and oneself, and so on.

PTSD diagnoses may follow or be associated with experiences such as natural and man-made disasters, having been a victim of violence, including sexual violence, or of incarceration and torture, or other events where extreme terror, helplessness, or threat to life was experienced. The majority of PTSD diagnoses are in response to a single episode of adult trauma.

Judith Herman first used the term “complex trauma” in 1992 to describe a constellation of symptoms that occurred following chronic, repetitive, or prolonged trauma. She highlighted the fact that the central feature of the experience involved captivity: being unable to escape from unbearable experiences of helplessness, terror, and dread that overwhelmed existing defences. She drew on her clinical experience in working with adult survivors of child sexual abuse, Vietnam veterans, and those individuals who had experienced domestic violence, to suggest that for many the end result was characterized by a particular constellation of symptoms.

Alongside the symptoms of PTSD, Herman suggested that complex trauma might also lead to:

»affect dysregulation;

»revictimization;

»dissociation;

»somatization;

»identity disturbance.

Herman further highlighted that within this group, characteristic personality changes developed and a vulnerability to repeated harm towards self or others.

Clinicians working in a wide variety of settings recognized this description and found it a helpful way of understanding what their patients were struggling with in relation to their traumatic experiences. Many of these patients had received multiple other psychiatric diagnoses leading to different therapeutic interventions, many of which failed to link their current difficulties with their experiences of trauma. A growing understanding of the neurobiology of trauma led to a flourishing of therapeutic responses to complex trauma, further enhanced by the growing evidence base for treating PTSD from a single episode of trauma.

From the 1970s onwards, political pressure from anti-war and feminist movements brought the reality of complex trauma for these different groups more to the fore. In more recent years, the tidal surges of refugees across the world in response to torture, rape, and imprisonment in their homeland has become increasingly part of the daily reportage on news channels. Institutionalized sexual abuse of children has been formally recognized by governmental inquiries in Australia and the United Kingdom, while the unmasking of celebrity perpetrators has become almost commonplace. The growing recognition of systematized child sexual exploitation has also been evident, with high-profile cases in Rotherham, Oxford, Telford, and Rochdale. Within the psychiatric and psychological fields, a growing recognition of the importance of a trauma history in the development of multiple diagnoses, including personality disorder, depression, psychosis, substance misuse and dependence, anxiety disorders, and so on, has accumulated with considerable force. This has led to a growing recognition of the need for Trauma-Informed Care to be incorporated into all aspects of mental health. Adverse Childhood Experiences (ACEs) studies clearly demonstrate that cumulative ACE scores show a high correlation with numerous mental and physical problems in adults, including heart disease, Type 2 diabetes, and respiratory disease (Felitti, 2002).

Despite all this, it has taken over 25 years for psychiatric classificatory manuals to incorporate a diagnosis of “complex trauma” or “complex PTSD”. The eleventh edition of The International Classification of Diseases (ICD-11; WHO, 2022) includes a diagnosis of complex PTSD (C-PTSD), which is defined as a disorder that arises after “exposure to a stressor typically of an extreme or prolonged nature and from which escape is difficult or impossible”.

ICD-11 describes PTSD as having three core elements:

1. re-experiencing the traumatic event(s) in the present;
2. avoidance of these intrusions;
3. an excessive sense of current threat.

When this definition of PTSD is combined with the following criteria for disturbances in self-organization, a diagnosis of C-PTSD may be made:

1. Disturbances in affects: may include difficulties in emotional regulation (hyperactivation and deactivation) and behavioural disturbances, such as self-destructive acts, reckless or violent behaviour.
2. Disturbances in self-concept: may include feelings of guilt, shame, and failure, alongside belief in oneself as diminished, defeated, or worthless.
3. Disturbances in relational functioning: difficulty in feeling close to others, avoiding contact with others, and lack of interest in personal engagement.

Preliminary studies using this ICD-11 definition and incorporating the use of the International Trauma Questionnaire (ITQ; Dokkedah, Oboke, Ovuga, & Elklit, 2015) suggest that C-PTSD is common in clinical and population samples; in clinical samples it is more commonly observed than PTSD. In a US population sample, lifetime prevalence for C-PTSD was found to be 3.3%, with women twice as likely to meet the criteria as men. Prevalence estimates in a US veteran sample were 13% (Wolf et al., 2015), while in a treatment-seeking outpatient sample, 75.6% met the proposed ICD-11 criteria for C-PTSD. Cumulative childhood interpersonal violence was a stronger predictor for C-PTSD than PTSD, and C-PTSD was associated with a greater comorbid symptom burden and substantially lower psychological wellbeing (Karatzias et al., 2017).

The inclusion of C-PTSD within ICD-11 has facilitated the development of rating scales such as the ITQ and the publication of studies such as those cited above. It allows for rigorous examination of the descriptor symptom clusters and will in time facilitate a greater understanding of the disorder as a whole. Clearly this leaves the evidence base for the effectiveness of therapeutic interventions in its infancy. In the intervening years from Herman’s original description to the present day, clinicians have attempted to find ways to facilitate therapeutic healing for these patients.

In this chapter I describe how the initial consultation with a traumatized patient is informed by an understanding of the impact of complex trauma at a neurobiological level, how it impacts on attachment, and how one might understand what is happening in the room from a psychoanalytic perspective. I believe the assessment and understanding of the difficulties the patient brings and the initial development of a therapeutic alliance requires holding in mind both trauma and psychoanalytic paradigms and that the two are mutually useful in the process of understanding and engaging the patient.

It may be helpful to explain that much of what I am describing in relation to C-PTSD is centred on the experience of developmental trauma. It is also true that individuals may develop C-PTSD from chronic, repetitive traumatic experiences in adulthood, such as the experiences of asylum seekers, survivors of torture, or adult survivors of interpersonal violence. There is a growing body of evidence that the risk of adult experiences leading to PTSD is greatly increased if there is a history of childhood trauma (or even trauma in the family), and resilience is enhanced if there has been a secure attachment figure in childhood.

The setting

To understand the importance of the setting and the many details that need to be considered in this context, it is helpful to begin by summarizing the body’s response to the experience of threat—sometimes referred to as the “flight-or-fight” response. This is a built-in survival response to potentially life-threatening situations. The experience is registered in the brain, particularly the limbic system where the amygdala resides. Van der Kolk (2014) described the amygdala as the smoke detector in the brain, the apparatus that registers the possibility of danger and sets in motion the stress response system to the event to facilitate the fight/flight response through the sympathetic nervous system—one part of the autonomic nervous system (ANS)—and the release of adrenaline. Activation of the hypothalamus leads to triggering of the hypothalamic–pituitary–adrenal (HPA) axis, central to the stress response, which ultimately leads to the release of cortisol.

The fight/flight response facilitates immediate action. It causes a shutting down of body functions that are not necessary requirements (such as the immune and digestive systems) and gives extra help to those functions most needed.

These include:

»Rapid heart beat and breathing: The body increases heart rate and respiration rate in order to provide the energy and oxygen to the body that will be needed to fuel a rapid response to the danger.

»Pale or flushed skin: As the stress response starts to take hold, blood flow to the surface areas of the body is reduced and flow to the muscles, brain, legs, and arms are increased; the body’s blood clotting ability also increases in order to prevent excess blood loss in the event of injury.

»Dilated pupils: The body also prepares itself to be more aware and observant of the surroundings during times of danger; there is dilation of the pupils, which allows more light into the eyes and results in better vision of the surroundings.

»Trembling: Muscles become tense and primed for action; this tension can result in trembling or shaking.

If the danger passes, all of this will usually settle over 20–30 minutes.

However, if the situation is such that fighting or fleeing will not suffice or are deemed to be impossible, the third response is to freeze. This is mediated by another part of the ANS known as the parasympathetic system mediated through the dorsal vagus nerve. This is the most primitive reaction in evolutionary terms to danger and involves complete shutdown of our systems, immobilization, and dissociation. It is the “rabbit in the headlights” or the “playing dead” mouse in the deadly cat and mouse game. I will return to the freeze response when we consider dissociation in a later section.

Stephen Porges (2011) describes a third element of the ANS called the ventral vagus. This is the most evolutionarily advanced component of the system and links the brainstem, heart, stomach, other internal organs, and facial muscles. It is involved in complex processes of attachment, bonding, empathy, and social communication. It is opposite in its effects to the sympathetic fight/flight system and shuts down when we are threatened.

If the stress response system as outlined above is repeatedly, chronically triggered by trauma such as child abuse, this may have a profound effect on the developing brain. Findings from a number of studies consistently demonstrate higher activation of the amygdala—the part of the limbic system that is the centre for strong emotions such as fear and rage. This higher activation is akin to setting the dial on high for response to any possible threat causing a full-scale stress response, with the propensity to chronic activation of the sympathetic nervous system (Palombo et al., 2015; Thomason et al., 2015).

The hippocampus is responsible for forming memories and in retrieving them also provides context and comparison. Childhood trauma is often associated with smaller hippocampi in adulthood (Anderson et al., 2008) This can reduce the capacity to measure the degree of threat if one is less able to contextualize against other memories, to learn from experience. So, each danger signal is potentially felt to be extreme and requires the full stress response. Adding to this situation is the recognition that many traumatized children show reduced activation in the ventromedial prefrontal cortex, which is a vital area for emotional regulation, self-reflection, and empathy (Mehta et al., 2009).

Many in the field of trauma describe a phenomenon called “top-down processing”. It is a description of how executive functions in the brain are used to inhibit and manage disruptive emotions and sensations. We...