It has taken a long time for the myriad effects of childhood trauma to be named and understood. Doing so is a precursor to effective treatment. While the diagnosis of post-traumatic stress disorder (PTSD) dates from 1980, the term ‘complex’ trauma (multifaceted, more common, pervasive and potentially damaging) was not widely used at that time. Recognition that 'the most severe dysregulation occurred in people who, as children, lacked a consistent caregiver’, and that 'chronic misattunement’ as well as diverse forms of abuse compromise subsequent development, is more recent (van der Kolk, 2011: xi-xii).
We have accumulated vast amounts of knowledge about 'complex trauma’ in the last two decades. (van der Kolk, 2009: 455; Herman, 2009). Yet despite the term ‘complex’ trauma being used more commonly we need to consistently reiterate the differences between it and single-incident PTSD. Many health professionals do not recognise them, even though complex trauma is associated with more extensive symptoms and impairments (Courtois and Ford, 2009: 18; van der Kolk, 2003: 170-171).
Complex trauma, which relates to diverse and often cumulative adversities, is often interpersonally generated and is the frequent legacy of childhood trauma. It is `complex’ because it places the person at risk not only for recurrent anxiety (including PTSD) but for `interruptions and breakdowns in the most fundamental outcomes of healthy psychobiological development’ (Courtois and Ford, 2009: 16; emphasis added). The PTSD diagnosis simply does not encompass the full dimensions of complex trauma. (Courtois and Ford, 2009: 18; van der Kolk, 2003: 170-171).
Standard ‘diagnostic’ classificatory systems generally do not consider underlying factors, such as trauma, particularly when they manifest in diverse ways. The terms `comorbidity’ and `Unspecified Dissociative Disorder’ (the latter of which, along with `Other Specified Dissociative Disorder’; OSDD, replaces in DSM 5 the previous term `Dissociative Disorder Not Otherwise Specified’ [DDNOS]), for example, evidence the limits of diagnostic compartmentalisation.
People who experience the effects of complex trauma exhibit a wide array of presentations. Using medical terminology these are commonly labelled as ‘symptoms’, and, clustered together, they generate diverse and often multiple diagnoses. Historically the clinical focus has been on surface presentations, rather than on context and underlying features. As a result, the origins and even existence of complex trauma are often undetected, inappropriately treated, or unaddressed.
The differences between `complex’ and `single incident’ [i.e. PTSD) trauma are additionally important because they have clinical implications. Research in complex trauma-related presentations suggests that early `exposure’ to distressing memories and experience in therapy may be less appropriate for treatment of complex trauma (van der Kolk, 2003; Courtois & Ford, 2009). In contrast to single-incident PTSD (which, if adult in onset, generally means the person has previously had the capacity to self-soothe) the client with complex trauma - particularly if it relates to early life experiences - `does not start with this advantage’ (Shapiro, 2010).
For this reason expert consensus guidelines for the treatment of complex trauma endorse a phased approach. In the first phase the therapist/counsellor helps the client to develop the capacity to self-regulate. In complex trauma, this capacity is typically massively disrupted and is a distinctive and destructive legacy of such trauma. Research also shows that effective treatment of complex trauma needs to be `bottom up’ as well as `top down’, and involve all dimensions of the person; body as well as mind and emotions (Fosha, 2003; van der Kolk, 2003; Ogden, 2006).
The release of guidelines for treatment of complex trauma was a milestone to enhance clinical understanding and optimal treatment for those affected. In 2012, our organisation released Practice Guidelines for Treatment of Complex Trauma and Trauma Informed Care and Service Delivery.
The Practice Guidelines were launched in Parliament House, Canberra, in the states of WA, Qld, Victoria and NSW and at the 29th Annual Conference of the International Society for the Study of Trauma and Dissociation (ISSTD) in Los Angeles. The ASCA guidelines have been nationally and internationally acclaimed and endorsed as well as widely accessed. More than 13,000 copies have been either purchased or downloaded. The ISSTD, the premier international organisation focussed on complex trauma, (which has also produced its own guidelines) unanimously endorsed them.
So where are we now? The DSM 5 has added a new dissociative subtype to the classification of PTSD. This is a step towards recognition of the complexity of the PTSD diagnosis as previously, the more complex forms were not recognised and partially subsumed.
While there still is no free-standing diagnosis of `complex trauma’ there is more evidence for the need for a constellation of presentations than for one of compartmentalisation. The current draft of the International Classification of Diseases (ICD-11), due for release in later this year, includes a diagnosis of complex post-traumatic stress disorder (World Health Organization 2014). In referring to the concept and treatment of complex traumatic stress disorders Herman (2009:xvii) contends that `it makes sense to pause and reflect on how far the field has come’.
Dr Cathy Kezelman, President/Director, Blue Knot Foundation
Dr Pam Stavropoulos, Head of Research, Blue Knot Foundation
Blue Knot Foundation (formerly Adults Surviving Child Abuse) The Last Frontier: Practice Guidelines for Treatment of Complex Trauma and Trauma Informed Care and Service Delivery (Sydney: 2012) http://www.blueknot.org.au/guidelines
Courtois, Christine A. & Ford, Julian D. Treating Complex Traumatic Stress Disorders: An Evidence-Based Guide (New York: The Guilford Press, 2009).
Fosha, D. `Dyadic Regulation and Experiential Work with Emotion and Relatedness in Trauma and Disorganized Attachment’, ch.6 in Solomon, M.F. & Siegel, D.J., ed. Healing Trauma: Attachment, Mind, Body, and Brain (New York, Norton, 2003), pp.221-281.
Herman, J. `Foreword’ to Courtois & Ford, Treating Complex Traumatic Stress Disorders, pp.xiii-xvii.
Herman, J. Trauma and Recovery: the Aftermath of Violence, from Domestic Abuse to Political Terrror (New York, Basic Books, 2015 ]1997, 1992).
International Society for the Study of Trauma and Dissociation, Adult Treatment Guidelines, Guidelines for Treating Dissociative Identity Disorder in Adults (2011) http://www.isst-d.org/default.asp?contentID=49
Ogden, P, Minton K. & Pain, C., Trauma and the Body: A Sensorimotor Approach to Psychotherapy (New York: Norton, 2006).
Shapiro, R. The Trauma Treatment Handbook: Protocols Across the Spectrum (New York: Norton, 2010).
Siegel, D.J. `An Interpersonal Neurobiology of Psychotherapy: The Developing Mind and the Resolution of Trauma’, ch.1 in Siegel & Solomon, ed. Healing Trauma, pp.1-56.
van der Kolk, B.A. (2003) `Posttraumatic Stress Disorder and the Nature of Trauma’, ch.4 in Solomon & Siegel, Healing Trauma, pp.168-195.
World Health Organization. (December 9, 2014). ICD-11 Beta Draft (Joint Linearization for Mortality and Morbidity Statistics).