lecture 3 of 10: Complex trauma: preparing for treatment to ensure safety and re-traumatisation is avoided.

1. Lecture 3 Preparing for
treatment of
complex trauma
Complex Casework
Kevin Standish

3. 1. Learning outcomes
 To explore the best practices based on research
evidence, the process of recovery
 To identify the therapeutic stages in a phased
based relationship approach
 Create a safe therapeutic setting
 To understand the dynamics of the therapeutic
process

4. 2. RANGE OF TREATMENT
MODALITIES

5. 2. Range of treatment modalities
• When working with survivors of complex trauma,
practitioners will need to be mindful of a range of
treatment modalities that they can integrate into
their already existing therapeutic approach.
• In this integration a framework in which safety and
stabilisation are emphasised to minimise the risk
of re-traumatization.
• Many of the skills used come from CBT combined
with humanistic principles
• Whichever model is used, need to ensure that
core therapeutic goals are addressed

6. 2. Range of treatment modalities
 The therapeutic process needs to be sensitively
paced to provide more than symptom relief
characterised by some limited therapies: eg
brief CBT
 Clinical evidence indicates that healing from
complex trauma requires long-term therapeutic
intervention (minimum of two years of support)
 Counsellors need to consider if they can offer
such a commitment. If not they need to be able
to refer clients to a specialist agency is
required.

7. 2. Range of treatment modalities
 There are a range of alternative, body therapy
focused approaches like sensory motor therapy
and eye movement desensitisation and
reprocessing (EMDR), and relationship based
therapies like Emotional Focused Therapy (EFT)
 These best combined with therapies that
promote reflection, cognitive processing and
integration for example dialectical behaviour
therapy (DBT) and schema therapy (Young
2003)

8. 2.1.Core therapeutic goals

10. 3. ASSESSMENT

11. 3. Assessment
1. It is essential to assess the degree of post-
traumatic stress symptoms, dissociative
symptoms and overall level of functioning.
2. It helps to identify primary and secondary
symptoms as well as any associated disorders.
3. Primary symptoms consist of trauma reactions
elicited by the trauma.
4. Secondary symptoms represent attempts by
survivors to manage the primary effects such
as self harm, self medication and withdrawal.
5. Over time secondary symptoms lead to
associated disorders such as self-destructive
behaviour, substance dependency, chronic
depression and personality disorders.

12. 3. Assessment
1. Survivors of complex trauma who have been dehumanised
tend to benefit more from a warm, genuinely engaged,
human relationship than a distant or clinical one which is
driven by protocols and assessments.
2. An important element in the treatment of complex trauma
survivors is to avoid pathologising the clients. Pathologising
survivors taps into their deep rooted fears that they feel
inadequate, flawed or crazy.
3. It reactivates abuse dynamics in which reality is distorted
by someone more powerful than them. You need to guard
against such power dynamics so as not to re-traumatised
the client.

13. 3. Assessment
1.How assessment is approached plays an
important role in this process. An overly clinical
approach can be more destructive than an
informal and more discussion based approach in
the initial clinical assessment through
therapeutic dialogue.
2.You need to use your judgment in terms of
what is most coherent with your theoretical
approach, therapeutic style and what is most
helpful with the individual client.

14. 3. Assessment
1. You need to be familiar with the range of trauma
assessment scales and how they used. It is helpful to
ascertain the degree of trauma using a traumatic event
scale and to check the magnitude and intensity of trauma
reactions.
2. Sometimes clients do not initially present with complex
trauma or dissociative disorders and these emerged later in
the therapeutic process. Use assessment scales when these
emerged rather than a global generalised assessment.
3. The importance of using assessment scales is to assess the
survivors therapeutic need more accurately, to help
empower them to decide to what extent they can provide
effective therapeutic interventions with the client, or
whether they need to refer the clients to more specialist
agency.

15. 3. Assessment
1. Assessment needs to be ongoing throughout the
therapeutic process. It is important to keep track of
emergence of symptoms or difficulties and respond
appropriately to the need. It is also important
consolidate and integrate newly acquired knowledge
and skills for the client.
2. To engage clients with this and to highlight the
importance of collaboration, it helps to invite clients
to assess progress every six weeks in terms of symptom
reduction and what is helpful in the therapeutic
process and what is less helpful.
3. This reduces the power dynamics in the therapeutic
relationship and allows the client to feel in control and
to take ownership of their recovery and healing

17. 4. THE ROLE OF PSYCHO-
EDUCATION

18. 4. The role of Psycho-education
1.An important part of recovery is to make sense of
traumatic experiences and reactions to restore a
sense of control.
2.This is facilitated through psycho-education.
3.This involves sharing information to enhance
awareness and improve cognitive understanding.
4. This equips clients with the knowledge about
trauma and the process of recovery so they can
develop reflective functioning and
metacognition to make sense of the
experiences.

19. 4. The role of Psycho-education
1. This allows clients to normalise their reactions and
begin to take more control of their emotions.
2. To maximise the effect of Psycho education
counsellors need to be mindful of how knowledge is
conveyed so as not to patronise or overwhelm the
client.
3. It needs to reflect the clients need at a specific time
and be accessible to them in order to make use of it.
It is important to ask clients if they would find the
information helpful rather than assuming they need to
know particular information.
4. The sharing of information needs to be carefully
paced and collaborative with the client in order to
avoid being "the expert".

20. 4. The role of Psycho-education
1. As dissociative clients are often not present, or
switch between conscious awareness and
dissociation, they have difficulty in receiving,
processing and storing information.
2. This is especially the case when they are
exploring experiences that are painful and
threatening, when they most likely to
dissociate, rendering information meaningless.
3. It is important to monitor to what degree
information has been understood and
integrated at regular intervals, normally
through homework exercises.

21. 4.1.Areas of Psycho education
1.Much of psycho-education will take place in the
early stages of therapy in order to help survivors
feel more in control of trauma reactions, to
understand the therapeutic process and
understand the nature and impact of trauma.
2.Psycho education needs to include information
on specific areas of difficulty that the client is
grappling with.
3.The most common of these include dissociation,
shame, self harm, self medication, substance
abuse and sexuality.

23. 5. THE THERAPEUTIC PROCESS

24. 5. The therapeutic process
1. Given the betrayal of trust and disruption of attachment
bonds, it is critical that a safe and secure base
(Bowlby) is created in which the survivor can work
through traumatic experiences into which the therapist
can bear witness.
2. This function is similar to what Winnicott describes as
"holding" and Bion as "containing". In this sense secure
base is also similar to therapeutic alliance.
3. It is only within a human relationship that the
dehumanising effects of complex trauma can be
reversed

25. 5. The therapeutic process
1. As traumatic experiences are associated with
abandonment and aloneness, counsellors must
guard against being too distant and clinical.
The need to listen with both head and heart to
provide an engaged therapeutic stance.
2. In other words Rogers core conditions need to
be met.

26. 6.CREATING A SAFE
THERAPEUTIC SETTING

27. 6.Creating a safe therapeutic
setting
1. As trauma survivors sense of safety is compromised, it is
essential that you create a safe therapeutic setting that
will act as a "secure base" for clients.
2. You need to provide a predictable and consistent
therapeutic space to reverse the unpredictability and
inconsistency associated with complex trauma.
3. You need to ensure that therapeutic space is safe from
intrusions, loud and unexplained noises to minimise
trauma reactions.
4. They need to feel safe in contained and reduce the need
for hyper-vigilance to focus on establishing internal
safety.

28. 6.Creating a safe therapeutic
setting
1. Re-experiencing trauma can revive terror states
in which survivors will be overcome by nausea or
the need to evacuate the bowels.
2. They need to know that they have access to a
toilet during the session and that it is permitted
as fear of vomiting in the session may prevent
the therapeutic process.
3. Clients will not express their needs and will
endure discomfort rather than ask for help.
4. It is important to be proactive in offering the
support needed, and have a glass of water and
tissues etc available in the therapeutic space.

29. 6.Creating a safe therapeutic
setting
 Consistent use of the same room is important
 Changes to room best avoided

30. 7.ATTACHMENT DYNAMICS IN
THE THERAPEUTIC PROCESS

31. 7.Attachment dynamics in the
therapeutic process
1. As a relationships are experienced as dangerous rather
than a source of pleasure, you will need to monitor
attachment dynamics that emerged in the therapeutic
process.
2. As clients have had insecure attachment in childhood,
the ability to connect will be hindered by an
approach/avoidant behaviours
3. You will need to monitor your own attachment style in
response to the survivor and how this influences the
therapeutic process.
4. This will help enhance the therapeutic dance between
client and counsellor and manage dynamics such as
idealisation and vilification of the counsellor

32. 7.Attachment dynamics in the
therapeutic process

33. 8. POWER AND
CONTROL

34. 8. Power and control
1. It is vital to pay attention to power and control dynamics
and ensure these are minimised.
2. Survivors know all too well what it feels like to be
controlled by someone else, and to feel they have no
control over their body, feelings thoughts or actions.
3. Counsellors need to provide opportunities for survivors
to gain control by providing a genuinely collaborative
therapeutic alliance, it would enable survivors to take
ownership of the healing.
4. This is best achieved by encouraging clients to set
personally meaningful goals and to pace therapeutic
work

36. 8. Power and control
1. Counsellors will need to be client led rather
than imposing a rigidly held theoretical
orientation or prescribed therapeutic
techniques. This requires flexibility in how
they work with their clients.
2. An emphasis must be placed on establishing a
mutually respectful relationship in which the
client feels valued and validated as an
individual, not just as a survivor of complex
trauma in which the central organising
principle is the trauma and victimisation.

37. 8. Power and control

38. 9. BOUNDARIES

39. 9. Boundaries
1.Boundaries play an essential part in the
development of a safe space in which trust
is developed.
2.There is a balancing act between
establishing safety needs whilst leaving
control to the client.
3.Counsellors must make sure they set
appropriate boundaries to keep both client
and counsellor safe, in which they feel
contained but flexible.

40. 9. Boundaries
1. Core boundaries in trauma therapy involve being:
 Explicit
 Boundaries of safety
 Confidentiality
 Duration of therapy
 Length of session
 After hours session contact
 Touch
 Support in an emergency
2. Counsellors need to be explicit in stating agreed
boundaries to provide these in a written form.

41. 10. PHASES OF TREATMENT

42. 10. Phases of treatment
1.In the therapeutic process it is essential to
promote client safety and to minimise re-
traumatisation.
2.It is crucial that you do not explore the trauma
narrative until the survivor has acquired
sufficient skills to feel in control of trauma
symptoms, and there is an improvement in
daily functioning.
3.This enables survivors to manage primary
symptoms of trauma and to learn vital skills to
reduce secondary symptoms such as self harm
and substance abuse.

43. 10. Phases of treatment
 Phase 1: safety, stabilisation and engagement
measured in skills, not time
 Phase 2 trauma memory, emotion processing,
an application to the present
 Phase 3:future considerations reconnection to
self and post-traumatic growth

44. Seminar: Challenges of
treatment
 What do you think are the major challenges in
the treatment of complex trauma?
 Professional Challenges?
 Challenges in the Therapy process?
 Challenges in session?
 Challenges due to dissociation?
 Core challenges to the counsellor?
 Read chapter 6 Sanderson (2013)

45. Reading list
 Core readings
1. Sanderson (2013) Chapter 5 Safe Trauma Therapy
 chapter 8 the process of recovery.
2.Courtois & Ford (2009) chapter 4. Best Practices
 in Psychotherapy for Adults, Christine A. Courtois, Julian D. Ford,
and Marylene Cloitre
3. Courtis & Ford (2013):
 Chap 3 Preparing for treatment of complex trauma
 Chap 4 Treatment Goals and Assessment
Advanced reading
 4. Courtois & Ford (2009) Chap 2. Neurobiological
 and Developmental Research: Clinical Implications,
 Julian D. Ford