Working With Complex Trauma (Foundational)

Trauma is prevalent in society and occurs in complex as well as `single incident’ forms. Complex trauma can be hard to identify, poses a range of treatment challenges, and is generating a research base with which it can be hard to keep up. Correspondingly, applying the core principles of effective therapy for complex trauma to clinical practice is an ongoing task. This foundational course in working with complex trauma addresses both these dimensions.

Part A (Core Principles and Underpinning Insights) presents essential information on the nature of complex trauma, dissociation, memory, the development of self (a process which early life trauma can disrupt) and re-enactment (i.e. `the compulsion to repeat’ trauma if it remains unresolved).

Part B (Treatment Implications and Micro skills) translates the insights of Part A to direct clinical work. Participants will experience a mix of learning styles and extensive resources and references will be made available.

MODULE DETAILS

PART A: CORE PRINCIPLES AND UNDERPINNING INSIGHTS

Session 1 Complex trauma, its forms and impacts (2 hours)

Complex trauma presents in diverse ways with a range of impacts it can be challenging to identify. The prevalence of complex trauma, which can underlie contrasting presentations, also means that all health professionals need to attune to it. This is because `[i]n contrast to the traumatized person who has experienced a sense of safety and well-being prior to onset of the (single-incident) trauma, the survivor of complex trauma does not start with this advantage’ (Shapiro, 2010). This session addresses the nature, forms, and impacts of complex trauma and the implications for working therapeutically with people who experience it.

Learning objectives :

• Ability to distinguish complex trauma from single-incident PTSD
• Increased capacity to attune to and identify complex trauma in its many forms and impacts
• Awareness of how coping strategies to protect against early life trauma can lead to symptoms of physical and psychological ill health in adulthood if the underlying trauma is not resolved and the treatment implications.

 Session outline :  

• Defines and discusses the differences between complex and `single-incident’ trauma
• Identifies the impacts of trauma on the brain and body
• Introduces the neurobiology of attachment and the role of adverse childhood experiences in generating early life (complex) trauma and adult health problems
• Considers the relationship between symptoms and coping strategies in effective treatment of complex trauma

Session 2 Dissociation and why we need to know about it (2 hours)

Dissociation, which in simple terms means not being psychologically present in `the here and now’ and which can take many forms, poses major challenges for clinicians because it is often unrecognized (`Many people in the mental health profession do not know what dissociation looks like or how to assess for it’; Danylchuk & Connors, 2017). This is despite research findings that dissociative disorders are prevalent in the general population, disproportionately so within clinical populations, and that `severe dissociative symptoms’ are a feature of complex trauma (Schwarz, Corrigan et al, 2017: Van der Hart, Nijenhuis & Steele, 2006). This session addresses the nature and varieties of dissociation with particular reference to its role and implications in the treatment of complex trauma.

Learning objectives

• Awareness of the importance of dissociation in its many forms  
• Attunement to degrees of dissociation (mild, moderate, severe) and understanding of why even mild forms of it can impede therapy if left unaddressed
• Recognition of the relationship between complex trauma and dissociation
• Identification of the five dissociative symptoms
• Awareness of how dissociative responses which are initially protective in childhood can contribute to coping strategies which become dysfunctional in adulthood
• Enhanced ability to identify and effectively respond to complex trauma-related dissociation

Session outline

• Introduces dissociation in its several forms and the role of a continuum model in attuning to its different degrees and expressions
• Considers why `normal personality structure is shaped by dissociation’ (Bromberg, 2001) and what happens `when things go wrong’
• Addresses the frequent trajectory and severity of dissociation in complex trauma
• Presents ways in which complex trauma-related dissociation can be safely intercepted and worked with

Session 3 Memory is not unitary: conscious, nonconscious, and traumatic memory(2 hours)

Understanding of and ability to work with traumatic memory is critical to the resolution of complex trauma. Yet despite landmark texts which address the non-verbal features of traumatic memory and the role of the body (i.e. that `the body remembers’) the nature of traumatic memory – and indeed the nature of memory per se – is widely mischaracterized and misunderstood. This session presents current research findings on the complex network of subsystems we call `memory’, the need to distinguish contrasting kinds and varieties of memory, and the significance of this research for effective therapy with clients who experience the impacts of complex trauma.

Learning objectives

• Recognition of the non-unitary nature of memory, the differences between explicit (conscious) and implicit (largely non-conscious) memory, and the particular features of traumatic memory
• Awareness of how trauma, deriving from inability to process overwhelming experience, registers in the brain and body and is expressed in `physical sensations, automatic responses and involuntary movements’ (Ogden et al, 2006) rather than spoken language
• Understanding of how neurobiological research clarifies misconceptions about the nature of traumatic memory, the phenomenon of delayed conscious recall of traumatic experience, and the clinical implications for working with adults who experience the impacts of childhood trauma.

Session outline

• Differentiates and discusses contrasting types of memory with reference to the key distinction between explicit (conscious, largely verbalizable) and implicit (largely non-conscious, non-verbal) memory
• Focuses on traumatic memory as a particular and potent form of implicit memory with reference to neurobiological research findings
• Addresses the challenges traumatic memory poses to traditional `talk therapy’ and the need to incorporate non-verbal principles and interventions into effective clinical work irrespective of the modality applied
• Identifies and addresses issues pertaining to clinical work with clients whose traumatic memories relate to childhood experiences

Session 4 The nature and process of self: developmental trajectories and adult impacts and implications (2 hours)

While reference to the `whole person’ is common in diverse therapeutic modalities, clients who experience the impacts of complex trauma often do not experience themselves in this way. This means that effective therapy for complex trauma needs to adapt accordingly. In fact the notion of a unified self has been critiqued for some time (`It is the nature of the human mind to be subdivided…multiplicity is inherent in the nature of the mind’, Schwartz, 1995; `[t]hough the self is a unit, it is not unitary’; LeDoux, 2002). From this perspective, it is `how well we can keep it together, how harmoniously we can bridge, coordinate and even integrate the different parts of ourselves that determines how functional we are’ (Putnam, 2016). This session addresses the development and process of self, how healthy developmental trajectories are disrupted by early life trauma, and the differences between `normal multiplicity’ and dissociated self-states which are trauma-generated.

Learning objectives

• A framework for understanding the development of self with reference to a state theory of personality (Putnam, 2016)
• Understanding of how early life trauma can derail and disrupt self-coherence, continuity, and functioning
• Awareness of the important differences between `normal multiplicity’ and self-states which are trauma-generated

Session outline

• Discusses how personality integration, coherence and self-continuity are not innate but rather result from developmental and relational experience (`Constructing a mental self-continuity of consciousness, memory and identity is a task not a given’; Spiegel, 2018).
• Considers how `good enough’ caregiving in childhood assists links between mental states while suboptimal attachment impedes ability to move flexibly between them
• Introduces a non-unitary model of self and a state theory of personality which aids understanding of the state-changes and fluctuations to which we are all subject (`we are all multiple to some degree’; Putnam, 2016).
• Discusses the differences between `normal multiplicity’ and dissociated trauma-generated self-states and the implications for working with complex trauma

Session 5   Complex trauma and re-enactment (`the compulsion to repeat’) (2 hours)

It is well known that trauma is re-enacted but the re-enactment of trauma poses many clinical challenges. This is partly because unresolved trauma is often dissociated and non-verbal. While the basic trauma response of `fight/flight/freeze’ is now familiar, less attention has been paid to the third of these and to dissociative responses in which what cannot be expressed in words is interpersonalised and enacted including in the therapy room. Many clinicians recognize that trauma is enacted in the lives of their clients but are less attuned to how it plays out within the therapy relationship itself. This session addresses the interface between complex trauma and dissociation, which is interpersonalised in the form of enactments which occur within - as well as outside - the therapy room and which can derail the therapy unless identified and addressed.

Learning objectives

• Understanding of why and how unresolved trauma is repeated (`re-enacted’) and that complex trauma correspondingly entails complex re-enactments
• Recognition of how dissociated experience is enacted in the therapy room
• Identification of ways in which therapists, in interaction with their clients, participate in enactments
• Ability to assist clients to tolerate previously overwhelming relational experience via your own ability to recognise enactments in the therapy room which will in turn assist your capacity to navigate them and to resolve impasses and `stuckness’

Session outline

• Addresses how unresolved traumatic experience is relationally enacted via the process of dissociation
• Explains why enactments (`the interpersonalisation of dissociation’) are frequent and inevitable in therapy for complex trauma
• Addresses how to identify enactments in the therapy room
• Explains how unconscious communications of the client in the service of self-protection can elicit dissociated experience in the therapist (in which case identifying enactments in the therapy room is especially challenging)
• Considers how enactments in therapy for complex trauma can be navigated, `renegotiated’ and resolved

PART B: TREATMENT IMPLICATIONS AND MICROSKILLS

Session 6 Introduction to phased treatment for complex trauma (`the therapeutic rollercoaster’ Chu, 2011) (2 hours) 

Phase based treatment has long been endorsed by clinicians of complex, as distinct from standard (`single-incident’) PTSD. Consisting of three stages, which are not strictly linear, the rationale is that initial focus on affect regulation, improved functioning and self-care assists stabilization and thereby the ability to process traumatic experience and memories. This session introduces the phased therapy approach to treatment of complex trauma. It addresses the issues to which it gives rise, including criticisms of it, delineates the three phases, and how they apply in clinical context.

Learning objectives

• Awareness of the principles which underpin the phased approach to therapy for complex trauma
• Identification of the tasks applicable to each of the three phases of therapy

Session outline

• Introduces the key and characteristic features of phased therapy for complex trauma with reference to its history, longevity, and status in the context of contemporary debates
• Presents and describes each of the three phases (`bottom up and top down’)
• Describes the tasks which correlate to the phases of the staged treatment orientation and a framework for their clinical application

Session 7 Phase 1, Stabilizing and resourcing (2 hours)

The extensive impacts of complex trauma underline the importance of stabilization, affect regulation, and the capacity to self-soothe and tolerate emotion prior to the processing of traumatic experience (`It is almost impossible to overstate the importance of traumatized patients maintaining an appropriate level of functioning in their lives’; [processing] must be deferred pending the development of basic skills concerning relating and coping’; Chu, 2011). Acquiring the necessary skills requires resourcing, which takes many forms and which encapsulates in a single word the primary task of Phase 1. This session focuses on the multifaceted task of client resourcing in contexts of complex trauma, and the many issues and challenges it involves.

Learning objectives

• Identification of the diverse resources required by clients whose capacity to access them has been disrupted by the impacts of complex trauma
• Ability to distinguish `top down’ from `bottom up’ resources and basic ability to assist development of these via appropriate interventions
• Acquisition of containment skills with which to assist clients in the context of resourcing.

Session outline

• Revisits the wide-ranging impacts of complex trauma as signposts to the range of resources which need to be developed, acquired or reinstated in Phase 1 therapy for complex trauma
• Distinguishes and discusses somatic, cognitive, and relational resources in the context of their concurrent coexistence and introduces interventions and strategies for fostering them
• Addresses self-care in contexts of self-harm and longstanding traumatic reenactments, the challenges of establishing relational rapport in light of prior violations of trust, and the role of psychoeducation alongside active resourcing strategies.

Session 8 Working with diverse self-states (`parts’) (2 hours)

Reference to `parts’ of the personality is common in the psychotherapeutic literature and the term is widely used by clients and therapists alike. What we call `self’ is not unitary and mental life is subject to state fluctuation and change. To this extent `we all have parts’ (van der Kolk, 2015) and `[w]e are all multiple to some degree’ (Putnam, 2016). The language of `parts’, `ego states’, and `self-states’ is also helpful and non-stigmatising with respect to the problematic divisions of personality generated by trauma, disrupted attachment, and experiences of overwhelm, in which self-states are unintegrated and flexibility, continuity, and coherence are impeded. This session presents an introduction to `working with parts’ with particular reference to the crucial distinctions between standard ego-states which characterise health, and dissociated self-states which pertain to the impacts of complex trauma (and which `can range from very simple to extremely complex divisions of the personality’; van der Hart et al, 2006) Note that while reference to structural dissociation generated by severe early life trauma is included, this seminar does not equip participants to work with Dissociative Identity Disorder (DID).

Learning objectives

• Attunement to the differences between mild, moderate, and severe forms of dissociation and their clinical implications
• Awareness of the differences between standard ego-states (`parts’) and trauma-generated self-states and the clinical challenges posed by the latter
• Basic ability to use `the language of parts’ with all clients and awareness of the adaptations and supplementations required to standard ego-state therapy approaches when working with clients who experience the impacts of complex trauma

Session outline

• Addresses why `parts’ language and work is valuable both for clients in general and necessary for complex trauma clients in particular
• Identifies key differences between the ego states which characterize all subjectivity (Watkins & Watkins, 1997; Phillips & Frederick, 2010) and the contrasting but often hard to discern features of parts which are trauma-generated
• Considers the limits of standard interventions (e.g. regarding grounding techniques, boundary issues, and assumptions about `the whole person’) in the context of dissociated trauma-generated self-states
• Discusses `orienting to parts work’ in therapy for complex trauma as a natural extension of parts work with non-traumatised clients subject to appropriate qualifications, inclusions, and supplementations.

Session 9 Phase 2, Processing (2 hours)

The second stage of phased therapy for complex trauma – for which the client has a foundation via the resourcing of Phase 1 – is the processing of traumatic memory and experience. But what does `processing’ of traumatic memories mean and entail? This session addresses these questions. As traumatic memory is implicit and non-verbal, `nameless feelings…can be verbalized in words’ in Phase 2 (Chu, 2011) and it becomes possible `to bring nonverbal memory into a domain that is regulated by a different part of the brain’ (Ogden et al, 2006; re Siegel, 1999, 1995). It is crucial to understand that this is not about focusing on the content and detail of the memories per se. Rather it attunes to the impacts of traumatic memories on current functioning (`and that’s the focus of the therapy’, Danylchuk & Connors, 2017). Here the distinction between explicit and implicit memory is again underlined: `[a]t an explicit memory level, the client may have long known that the traumatic events are over. The work of phase 2 facilitates the felt experience that the danger is past’; Ogden et al, 2006).

Learning objectives

• Appreciation of the implicit, non-verbal nature of traumatic memory which in contrast to explicit memory is `split off from conscious awareness and stored as sensory perceptions, obsessive thoughts, and behavioral reenactments’ (Ogden et al, 2006, ref van der Kolk & van der Hart, 1989) and the implications for its processing
• Understanding of the shift in treatment orientation, supported by attachment and neuroscientific research, away from focus on the content and detail of traumatic memories to addressing the impacts on current functioning
• Recognition that the capacity of new experiences to challenge prior implicit traumatic memories challenges traditional `talk therapy’ and requires incorporation of `body based’ interventions
• Ability to apply at least two tools to assist processing of traumatic memory
• Ability to segue between Phase 2 processing and Phase 1 `return to resourcing’ if and as needed.

Session outline

• Situates the `processing’ of traumatic memory and experience as a Phase 2 goal of therapy for complex trauma with reference to current research and debates
• Discusses the relationship between verbal (conscious) and non-verbal (implicit) expression in the processing and resolution of traumatic memory and the role and implications of experiential processes and methods
• Introduces `ways, means, and tools’ by which the processing of traumatic memory can be assisted within the relational frame of phased therapy for complex trauma

Session 10 Phase 3, `Life after trauma’; post-processing (2 hours)

When clients are resourced (Phase 1) to the extent of being able to process traumatic memories (Phase 2) an additional third phase may seem unnecessary. Phase 3 often  receives less attention in commentary on the phased treatment approach to complex trauma relative to the previous two. But clients whose lives have been disrupted by the impacts of complex trauma face contrasting issues in the `post-processing’ period. Adjusting to `life after trauma’ presents a new set of challenges, including emancipation from trauma-related beliefs and behaviors which may have existed for decades. It is also not uncommon for clients to encounter new areas of unresolved trauma in the Phase 3 period, in light of increased ability to engage with experiences of distress which could not be approached before. This session addresses the final phase of therapy for complex trauma in which increased integrative capacity includes enhanced ability to mentalise (i.e. attune to the internal experience of others as well as self, which is required for responding to social cues and enhanced interpersonal relationships; Fonagy et al, 2002). Phase 3 involves `consolidation of gains, achieving a more solid and stable sense of self, and increasing skills in creating healthy interactions with the external world’ (Chu, 2011).

Learning objectives

• Identification of Phase 3 tasks, goals, and challenges
• Awareness of the potential emergence and/or recurrence of painful memories for clients in the `post-processing’ period
• Skills to assist clients to address residual trauma-related cognitions and behaviors which may impede adjustment to `life after trauma’ and general well-being

Session outline

• Considers the specific tasks of Phase 3 therapy for complex trauma in light of potential and contrasting challenges clients may experience in the `post-processing’ period
• Discusses the nature and process of mentalization (Fonagy et al, 2002, 2004) and its importance for client quality of life
• Addresses the frequently non-linear nature of phased therapy for complex trauma and how Phase 3 applies in this context.