Treating Complex Traumatic Stress Disorders: An Evidence-Based Guide
Edited by Christine A. Courtois, Ph.D., Julian D. Ford, Ph.D.
Reviewed by Kristina Muenzenmaier, MD*
Research on the impact of acute traumatic events and the treatment of PTSD has advanced during the last decade. However, the effects of prolonged and repetitive exposure to interpersonal trauma such as war, torture or childhood abuse are more pervasive, particularly if the exposure occurred during childhood resulting in disturbances of identity formation and psychological development. In Trauma and Recovery (1992), Judith Herman first outlined the concept of Complex Post Traumatic Stress Disorder (CPTSD) recognizing that repetitive trauma can have a severe impact on a person's self image, relations to others and world view as well as lead to symptoms of affect dysregulation, somatization and dissociation.
Herman argues that those symptoms rather than being described in separate diagnostic categories should be combined and seen as one complex syndrome or "spectrum of conditions" (p.125). Currently the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) has not yet incorporated the conceptualization of CPTSD into its classification system. "Disorder of Extreme Stress Not Otherwise Specified" (DESNOS) is vague as to its definition and complex trauma related symptoms still are described as separate and distinct diagnostic categories such as somatization or dissociation, while PTSD is classified under anxiety disorders.
The debate over whether CPTSD will be included in the DSM-V as a separate diagnostic classification is still ongoing. More recently mental health professionals working with children have argued for the need to add "Developmental Trauma Disorder" to the section on childhood disorders. However, despite many clinicians and researchers endorsing the validity of CPTSD as a separate concept, such as in this volume, it still remains uncertain whether CPTSD will be incorporated in the new DSM-V Manual.
Treating Complex Traumatic Stress Disorders: An Evidence-Based Guide, edited by Christine A. Courtois, PhD, and Julian D. Ford, PhD, is the first comprehensive overview on assessment and treatment of Complex Traumatic Stress Disorders. Both authors are experts in the field and have worked as clinicians with trauma survivors facing the clinical reality of complex manifestations of trauma. They have pioneered new treatment approaches and serve as teachers and supervisors in the field. Their work includes a wide range of topics including challenges clinicians face when working with this population (e.g. "false memory" debate, ethical dilemmas, vicarious traumatization, and special considerations related to work with adolescents).
The book is divided into three parts. Part I provides an overview over the definition and the concept of CPTSD and discusses the latest research findings in neurobiology and developmental psychology. Assessment tools for the sequelae of complex traumatic stress disorders, abuse history and attachment styles are presented. Psychotherapeutic trauma treatment approaches are outlined according to Best Practices both for adults and adolescents. Cultural considerations, treatment alliance and the impact of trauma on the clinician who works with this severely traumatized population represent important aspects of the therapeutic principles. Part II deals with individual treatment approaches of complex traumatic stress disorders ranging from psychotherapeutic approaches to pharmacotherapy. Part III addresses group and family approaches in the treatment of complex traumatized populations.
There are 33 contributing authors (including the editors), and all are involved in the field of complex traumatic stress disorders and have developed either assessment approaches and/or developed targeted treatment interventions for this difficult-to-treat patient population. All the chapters are extremely well written and very informative. Each chapter makes a significant contribution to this important, fast developing field. While space will not permit me to review each chapter, I just want to highlight a couple from each section.
Julian Ford, who has developed treatment models and conducts research related to CPTSD (and done as much as anybody to bring this work to our attention), provides a thorough overview of the latest findings in neurobiology, development and attachment research and discusses the implications for treatment in a chapter titled "Neurobiological and Developmental Research: Clinical Implications."
Daniel Brown examines the connection between early childhood trauma and attachment and challenges the assumption that early childhood trauma inevitable leads to the development of Complex PTSD. Instead, he argues, the outcome is mediated by early family environment and attachment style. In his study with men who were sexually and physically abused as boys, if the attachment during early family life was "secure but disrupted" due to external circumstances (e.g. death, lack of money) the outcome differed from that of men who experienced an "extremely disorganized and abusive" family environment (e.g. substance abuse, violence etc.) leading to disorganized and disrupted attachment. This deepens our understanding of the need to pay attention to attachment style and psychological development if we are to be successful in treating trauma of individuals who were experiencing it.
Various aspects such as patient's presentations, helper's own history and personality characteristics and the socio-cultural context and work environment all may contribute to vicarious traumatization, triggering feelings of helplessness, lack of control and self doubt in the care giver. One chapter, "Living and Working Self-Reflectively to Address Vicarious Trauma," by Laurie Ann Pearlman and James Caringi, has helpful suggestions for clinicians to become aware off so that they can practice self care when working with severely traumatized people.
"Sensorimotor Psychotherapy" is described by Pat Ogden and Janina Fisher as a new way of working with trauma through body therapy using a combination of psychodynamic, cognitive behavioral and somatic approaches. Since trauma triggers physiological changes the authors argue that somatic interventions are important in reducing the autonomic and physiological response of the body by teaching awareness and modifying the body's response to triggers. Some of the techniques include mindfulness, regulation of bodily arousal and processing of memory all in the context of a therapeutic relationship. Larger outcome data are not yet available for this approach.
A chapter on "Pharmacotherapy" includes a thorough discussion of psycho-pharmacological agents within the context of the sparse and limited research regarding efficacy of pharmacological treatment. The authors, Lewis A. Opler, Michelle S. Grennan, and Julian D. Ford, call for the need to treat specific target symptoms for complex PTSD such as dissociative symptoms and/or substance abuse/dependence. The authors underline the importance of the combination of psychotherapy and pharmacotherapy in order to address the complexity of clinical presentations including difficult to treat target symptoms. This includes a focus on the treatment alliance, which the authors argue needs to take into account the various attachment styles resulting from early childhood trauma. The discussion then can move beyond "treatment resistance" to an understanding of relationship difficulties based on early experiences of disrupted trust and autonomy. The case example poignantly underlines how a safe, respectful and empowering relationship can develop and lead to successful treatment despite difficulties in the treatment alliance early on.
In summary: This important text is a clear contribution to the position that complex traumatic stress disorders can be conceptualized as a separate clinical entity. Unique challenges such as defining and improving the diagnosis and developing and testing comprehensive treatment approaches are still ahead. Work with trauma survivors is complex and a simple symptom-focused approach ignores the difficulties encountered. Disturbances in affect regulation, arousal states, consciousness, self perception, systems of meaning and the impact of early disruptions in attachment need to be considered when developing targeted treatment interventions and treatment alliance. This book provides a complete overview over the current thinking regarding complex trauma disorders and should be required reading for all researchers and clinicians working with this population.
*Associate Clinical Professor of Psychiatry
Albert Einstein College of Medicine
Bronx, NY 10461