Post traumatic stress can result from a wide range of events including single incidents such as a car accident, an act of violence, or a natural disaster. PTSD is most often associated with the ongoing exposure to violence as experienced by combat veterans. Symptoms of PTSD are also associated with ongoing trauma that arises due to chronic neglect, abuse, exposure to domestic violence, or prolonged captivity. Such long-term exposure to trauma is referred to as complex PTSD (cPTSD) which accounts for the impact of repeated developmental trauma or neglect and the ongoing social stress such as bullying, discrimination, political violence, or the distress of being a refugee separated from family and country (Schwartz, 2016).
Many mental health practitioners are trained in the treatment of single traumatic events. However, clients more often come to therapy with an extensive history of trauma that often begins in childhood and continues into adulthood with layers of personal, relational, societal, or cultural losses. Clients arrive at the door with profoundly painful histories and well built-up defense structures to protect themselves from the pain. The wounds that they share with us might sound like this:
- I was physically abused as a kid. Now, I have chronic health problems and pain. Sometimes, I hope I’ll die in my sleep.
- I watched my father try to choke my mother. I took care of my mom after my he walked out. I was only three.
- My parents were survivors of the holocaust. I can still remember the emptiness and fear in their eyes. They lost everything. Now, I feel lost. Sometimes I just disappear.
- I was raised in a cult where I was sexualy abused. I survived by pretending that I was part of their world. Now, I don’t know what is true, who to trust, or who I am.
- No one has ever understood me. Now, I don’t know how to have a relationship. I feel utterly alone.
- I grew up afraid for my life. Now, I have lost my country. I am a refugee. I can never go home again. Each day I worry about the family that I have left behind.
Sometimes traumatic family dynamics or events become “normal” for the child. This distorted world was the only world known to the child. Children are dependent upon their caregivers and will form attachments; even if this is an attachment to the parents or caregivers who were the source of terror. In other words, the child acclimates to a dangerous world from which there is no escape. To the best of their ability, a child will make this a tolerable experience; even if this is accomplished by fantasy alone. Sometimes this process involves creating an idealized mommy or daddy within the mind and dissociating from the reality of the external world (Knipe, 2018). This can result in a deep fracture within the structure of self-organization (Fisher, 2017; van der Hart, Nijenhuis, & Steele, 2006). As a result, a child might develop inaccurate beliefs about themselves as a way to cope with the uncontrollable outer world. They might conclude that “There is something wrong with me,” “It’s all my fault,” or “I do not deserve to exist.” This process displaces the blame of the abuse or neglect onto the self. Perhaps, these thoughts arise because there is more control when a child believes that they are the source of the problem. Furthermore, as Dr. Jim Knipe (2018) suggests, it is utterly unfathomable for a child to contemplate that they are a good kid relying upon bad parents. Therefore, it is actually safer to believe that they are a bad child, relying upon good parents. Regardless, we see compromised meaning making as a dominant symptom of cPTSd.
Sometimes, the symptoms of cPTSD are related to early childhood preverbal events for which there are no clear images or memories. In some situations, the adult has little to no memories of the origin of complex trauma symptoms or has developed seemingly unrelated disturbances such as chronic pain or illness. Hypervigilance within cPTSD may present as being highly sensitized people’s body language, facial expressions, and voice tone. In some situations, we can view the dysregulation of arousal as a clue to disorganized early attachment or physiological experiences that occurred repeatedly throughout childhood. Often, these overwhelming arousal states will disrupt the client’s ability to function at work, home, or in relationships. Likewise, difficulties with affect regulation can be highly disruptive in the client’s life. These symptoms can come in the form of high arousal emotions such as anxiety, rage, or fear and low arousal emotions such as helplessness, hopelessness, despair, and depression.
The avoidance symptoms experienced by individuals with cPTSD might present as denying any disturbance related to childhood, idealizing parents, repressing feelings, minimizing the pain, or dissociating as a way to avoid feeling distressing emotions or sensations now. In addition, some clients might rely heavily upon addictive substances, emotional eating, or excessive exercising to avoid having to feel anything at all. A compassionate approach to treatment understands that dissociation is a learned behavior that once helped the client survive and cope with a threatening environment. Dissociation is a both a built-in physiological survival mechanism and a psychological defense structure. It helps the individual to disconnect from threatening experiences. Over time, dissociation becomes a well-maintained division between the part of the self that is involved in daily tasks of living and the part of self that is holding trauma related material (Fisher, 2017).
It takes tremendous courage for a client to confront traumatic memories and emotions. Successful treatment requires a compassionate therapeutic relationship and effective, research-based interventions. The integrative approach to treatment for Complex PTSD brings together Relational Therapy, CBT, DBT, EMDR Therapy, Parts Work Therapies, Somatic Psychology, and mind-body therapies. Together, these form a strength-based approach to trauma recovery aimed to increase resilience in your clients. This model has several key components, including being relationally focused, collaborative and client centered, culturally sensitive, phase based, and neurobiologically informed. It is based upon the treatment recommendations for complex PTSD (Courtois & Ford, 2009) and the neurophysiology of trauma recovery.
When working with Complex PTSD, a client centered approach to treatment becomes of paramount importance. Within this model, we recognize that there is no single therapeutic method that is appropriate or effective for all clients. Therefore, the work is client centered allowing the therapist to focus on maintaining the therapeutic alliance while focusing on the needs of each specific client within a social and cultural context. Clients with chronic, repeated, and/or developmental trauma often have a high degree of relational distrust. Their wariness of others has been a survival skill and as a result, they will sense the lack of authenticity or genuineness of any therapist. These, savvy, street-smart individuals can outthink any therapeutic intervention, a behavior that can be misinterpreted as “resistance.” However, we must remember that these survival skills have been honed over time and must be respected. Often these individuals do not have a framework for trust because their trust has been broken repeatedly. It is our job to move at a pace that creates safety and to remember that they are not broken; they are resilient and need to be seen for the incredible strength that they have. They are hurt and in need of compassionate care. The value of this collaborative approach to therapy allows for an open conversation regarding the timing and appropriateness of treatment interventions.
Therapists who emphasize “talk therapy” may predominantly focus on the role of the mind as influencing physical well-being. In contrast, mind-body therapies emphasize a bidirectional relationship between mind and body. Several mechanisms have been proposed to explain how mind-body therapies lead to psychological symptom reduction and behavior change. These explanatory mechanisms include control, increased distress tolerance, mentalization, and physiological regulation (Walsh & Shapiro, 2006). Some therapeutic interventions serve as “active control” tools that decrease impulsivity, provide increased access to coping skills, and provide clients with greater self-control over affect, behavior, and cognitions. This is closely related to Bandura’s (1977) concept of self-efficacy, which refers to the belief that your actions can influence successful outcomes in your life. Ongoing, repeated trauma exposure is associated with reduced self-efficacy. Development of this capacity improves wellbeing. There is also a second, equally beneficial aspect of control that comes from finding greater acceptance of situations or oneself. This is described as a yielding mode of control that arises through mindfulness practices of nonjudgment and curiosity.
Mind-body therapies assist the client with mentalization which is defined as the ability reflect upon your own thoughts, emotions, and motivations for behaviors (Fonagy, et al, 2005). This capacity to observe experience helps to increase distress tolerance and can lead to decreased emotional reactivity, anxiety, panic, chronic pain, and depression. Furthermore, mind-body therapies enhance self-compassion and the ability to compassionately view another person’s point of view enhancing interpersonal relationships. Lastly, mind-body therapies are effective because they engage physiological changes in the autonomic nervous system as measured by changes in vagal tone and heart rate variability (Trakroo & Bhavanani, 2016).
In all, this approach to care is resilience informed (Schwartz & Maiberger, 2019). Resilience is the ability to flexibly adapt to challenging, adverse, or traumatic life events (Luthar, 2003). This ability to “bounce back” from traumatic events is deeply connected to having the opportunity to work through difficult life experiences. Resilience is not a trait that you either have or do not have; it is a set of strategies that can be learned and practiced (Maddi, 2013). Resilience is not the same as optimism. Being overly focused on positivity and happiness has its drawbacks. Sometimes, a goal to stay positive results in overriding your authentic feelings. In addition, it is important to not resort to fantasy or idealism which can turn a blind eye to actual threats or barriers that are present in your life. In such cases, it is necessary to rely upon realism so that you stay grounded and oriented to your surroundings. However, too much realism can lead to skepticism or negativity. This can squash your dreams and hinder your ability to move forward. Thus, resilience is grounded in realistic optimism; a stance that allows you to both have your dreams while simultaneously setting attainable goals about how to achieve them. From here, you are better able to acknowledge barriers without become immobilized. Having a hopeful perspective is invaluable in trauma recovery and realistic optimism will help you take the necessary steps to walk the healing path.
Written by Arielle Schwartz, Ph.D. – www.drarielleschwartz.com
Dr. Arielle Schwartz, LP is a licensed clinical psychologist, author, EMDR Therapy consultant, and Certified Kripalu yoga teacher with a private practice in Boulder, Colorado. She earned her a Masters in Somatic Psychology through Naropa University and her doctorate in Clinical Psychology at Fielding Graduate University. She works with the Maiberger Institute offering therapist trainings in EMDR Therapy and Somatic psychology. She offers informational mental health and wellness updates through her heartfelt presentations, social media presence, and blog. She is the author of “The Complex PTSD Workbook: A Mind-Body Approach to Regaining Emotional Control and Becoming Whole.”and the co-author of “EMDR Therapy and Somatic Psychology: Interventions to Enhance Embodiment in Trauma Treatment”
Arielle is the developer of Resilience Informed Therapy, a strength-based, treatment model that includes EMDR Therapy, Somatic Psychology, and Relational Psychotherapy. She trained in EMDR Therapy in 2001 and is an EMDRIA Certified Consultant. Arielle has been the Program Advisor, and a trainer with The Maiberger Institute since 2008.
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Books For Sale – Arielle Schwartz:
Bandura, A. (1997) Self-Efficacy: The exercise of control. London: Worth Publishing
Courtois, C. A., & Ford, J. D. (2009). Treating complex traumatic stress disorders: An evidence-based guide. New York, NY: Guilford Press.
Fisher, J. (2017). Healing the fragmented selves of trauma survivors: Overcoming internal self-alienation. New York: Routledge.
Knipe, J. (2018). EMDR toolbox: Theory and treatment of complex PTSD and dissociation. Second Edition, New York: Springer.
Maddi, S. R. (2013). Hardiness: Turning stressful circumstances into resilient growth. New York: Springer.
Schwartz, A. (2016). The complex PTSD workbook: A mind-body approach to regaining emotional control and becoming whole. Berkeley, CA: Althea Press.
Schwartz, A. & Maiberger, B. (2018) EMDR Therapy and Somatic Psychology: Interventions to Enhance Embodiment in Trauma Treatment. New York: W. W. Norton
Trakroo, M. and Bhavanani, A. B. (2016). Physiological Benefits of Yogic Practices: A Brief Review. International Journal of Traditional and Complementary Medicine, 1(1), pp. 31-43.
van der Hart, O., Nijenhuis, E., & Steele, K. (2006). The haunted self: Structural dissociation and the treatment of chronic traumatization. New York: Norton.