These best practice guidelines are based on the research and recommendations of key complex trauma clinicians and theorists. This includes the work of Courtois, Ford & Cloitre, van der Kolk, Rothschild and others. They are drawn from Blue Knot Foundation’s Practice Guidelines for Treatment of Complex Trauma and Trauma Informed Care and Services Delivery (ASCA (Now Blue Knot Foundation), 2012) www.blueknot.org.au/guidelines
1. Facilitate client safety
`[A] first order of treatment is to establish conditions of safety to the fullest extent possible. The client cannot progress if a relative degree of safety is not available or attainable’ (Courtois, Ford & Cloitre, 2009 p.91)
2. Recognise the centrality of affect-regulation
Recognise the centrality of affect-regulation (emotional management; ability to self-soothe) as foundational to all treatment objectives and consistently foster this ability in the client. Facilitation of effective management of internal states is vital to a felt sense of safety, and as critical to experience outside the therapy session as to experience within it. Fostering of the ability to self-regulate should be a consistent task of therapy, involving, among other things, the teaching of strategies to self-monitor and self-intercept. Note that this task can be compounded in that existence of a coherent sense of self cannot be assumed.
3. Recognise the breadth of functioning impacted by complex trauma and needing acquisition and restoration
Recognise the breadth of functioning impacted by complex trauma and that acquisition, not just restoration (Courtois, Ford & Cloitre, 2009) of some modes of functioning may be necessary. Particularly if it dates to childhood, complex trauma can entail developmental deficits in self-organisation which do not apply in `single-incident’ PTSD (i.e. where there is no prior underlying trauma) – `As a group, clients with complex trauma disorders have developmental/attachment deficits that require additional treatment focus… treatment goals are more extensive than those directed at PTSD symptoms alone’ (Courtois, Ford & Cloitre, 2009 pp. 89-90).
4. Regard symptoms as adaptive and work from a strengths-based approach which is empowering of the client’s existing resources
A view of symptoms as `expectable and adaptive’ reactions to traumatic childhood experiences (Courtois, Ford & Cloitre, 2009 p.93) (i.e. as the outgrowth of normal responses to abnormal conditions) should inform clinical work.
5. Understand how experience shapes the brain, the impacts of trauma on the brain (particularly the developing brain) and the physiology of trauma and its extensive effects
Key aspects of this information should be sensitively communicated to the client, with a view to normalising distressing/problematic internal experience and responses for which they may otherwise hold themselves solely responsible. The effects of trauma on the brain, body and subsequent functioning should form part of the psycho-education which is a significant component of effective trauma therapy (Briere & Scott, 2006). While self-blame is unlikely to dissolve in the wake of psycho-education alone, current insights into the physiology of trauma and its effects need to be communicated to the client.
6. Encourage establishment/strengthening of support networks
Likely impairment of relational capacity may mean that supports are lacking or non- optimal. The therapeutic relationship itself fosters relational capacity as healthy support networks are worked towards.
7. Attune to attachment issues at all times and from the first contact point
While different in presentation and levels of functioning (including at different points in their lives) complex trauma clients have sustained assaults to their ability to connect with themselves and others. Attuning to attachment issues is vital to the therapeutic alliance and to effective working within it. It also assists recognition of potential indicators of whether the client is experiencing complex or single-incident trauma. Thus, there are significant reasons for therapist sensitivity, from the first contact point, to the relational style of the client (and thereby to the possibility of underlying trauma) (Shapiro, 2010).
8. Understand and attune to the prevalence and varied forms of dissociative responses, the differences between hyper and hypoarousal, and the need to stay within `the window of tolerance’
Structural dissociation represents an extreme form of defence in the face of extreme (inescapable) threat, and is a frequent feature of complex trauma when abuse begins early in childhood.7 Yet there are many and milder forms of dissociative response of which the therapist needs to be aware (`The more you know about dissociation, the more you automatically watch for its markers’) (Shapiro, 2010 p.36)
As responses to the experience of extreme anxiety, hyperarousal is characterised by agitation, while hypoarousal manifests as passivity, `shut down’ and withdrawal (Rothschild, 2011). Therapy must always remain within `the window of tolerance’; i.e. the threshold of feeling the client can accommodate without becoming either hyper or hypoaroused (Siegel, 2009).
9. Expect and be prepared to work with a variety of client responses, including a sense of shame which may not be readily apparent but which is frequently present and intense
Inability to self-regulate and to draw upon relationships to regain self-integrity engenders deep shame to which therapists should be attuned (`The feeling of shame is about our very selves – not about some bad thing we did or said but about what we are’; (Louis & Smedes, 1993 p.6) `shame also expands the clinician’s focus from fear or anxiety to the sense of a damaged self’) (Ford & Courtois, citing Fiering, Taska & Lewis, 2002).
10. Embed and apply understanding of complex trauma in all interventions
Recognising the limits of standard assessment tools and modalities in relation to complex trauma, (Courtois, Ford & Cloitre, 2009 p.89) also the extent to which these can be redressed via incorporation of the new clinical and research insights (see Pt 11 below) ensure that all interventions stem from understanding of current clinical and research insights into complex trauma.
11. Ensure the therapeutic model/approach promotes integration of functioning, and contains the `core elements’ consistent with research findings in the neurobiology of attachment
These include activation of/engagement with right-brain processes, attentiveness to the role and effects of implicit memory, and engagement with physical as well as cognitive and emotional processes – `we must attend to all three levels: cognitive processing… emotional processing… and sensorimotor processing (physical and sensory responses, sensations and movement’) (Ogden et al., 2006 p.140) While there are different ways of attending to these dimensions, current research elaborates the need for all three to be addressed therapeutically (`it is important to be able to engage the relevant neurobiological processes’) (Fosha; Siegel, 2003 p.229)
12. Recognise the extent to which the above requires adaptation of, and supplements to, `traditional’ psychotherapeutic approaches (i.e. insight-based and cognitive- behavioural)
Research in the neurobiology of attachment establishes the limits, as well as benefits, of `talk’, and the need for active addressing of physical, sensorimotor, and experiential processes as well as cognitions and verbal expression of emotion (`bottom up’ and `top down’) (van der Kolk, Ogden et al.,2006 )
13. Phased treatment is the `gold standard’ for therapeutic addressing of complex trauma, where Phase I is safety/stabilisation, Phase II processing and Phase III integration
The ability to tolerate emotion (self-soothe; regulate affect) is a primary task of treatment, and accounts for the importance of Phase I. Attempts to `process’ trauma in the absence of ability to self-regulate can precipitate overwhelm and re-traumatisation. `Processing’ of complex trauma is a Stage II task and should not be encouraged in the absence of the foundational self-regulatory work of Phase I. Hence the critical importance of Phase I to therapeutic outcomes – `Overstatement of the importance of this step is not possible; it is vital if trauma recovery is to be realised’ (Rothschild, 2011 p.57).
14. Therapy should be tailored and individualised; `one size does not fit all’
`Adapt the therapy to the client rather than expecting the client to adapt to the therapy’ Rothschild, 2011).
15. Therapists should be culturally competent and sensitive to gender, sexual orientation, ethnicity, age, and dimensions of `difference’
Awareness of, and attunement to, the potential impacts of `difference’ in its various forms (age, ethnicity, socio-economic status, and so on) is important for all therapeutic work, including and especially that with complex trauma. To the extent that clients are themselves attuned to therapist ambivalence (Wallin, 2007). It is imperative for therapists of complex trauma to be highly attuned to their own responses to perceptions of cultural, gender and other `differences’ in relation to their clients, and to be conversant with some of the valuable resources which can assist in this regard (Brown, in Courtois & Ford, 2009 pp.166-182)
16. Engage in regular professional supervision
`The intensity and complexity of transference-countertransference dynamics in complex trauma relationships are such that working without clinical consultation, at any level of helper experience, can pose great hazards for both clients and therapists’ (Pearlman & Caringi, in Courtois & Ford, 2009 p.214).
17. Attend to duration and frequency of sessions
Therapists should recognise that complex trauma treatment is generally longer than for many other presentations, and that while varying significantly according to the client, is `rarely…meaningful if completed in less than 10-20 sessions’ (Courtois, Ford & Cloitre, p.96) If economic or other constraints severely limit the number of available sessions, there are strong grounds to confine therapy to the `stabilisation’ (Phase I) stage (Rothschild, 2011)
Therapy is recommended to occur on a once or twice-weekly basis, with sessions ranging between 50 and 75 minutes for individual therapy and between 75 and 120 minutes for group therapy (Courtois, Cloitre & Ford, 2009 pp.96-97). Therapy should not exceed these recommended standards of frequency in the absence of compelling grounds for doing so, or destabilisation and dependence may result.
18. Recognise the importance of implementation of boundaries
`Boundaries are particularly salient with clients who have been subjected to violations, exploitations, and dual relationships’ (Kinsler, Courtois, Frankel, 2009 p.127) Boundaries should be mutually negotiated, and care should be taken to ensure that the client understands their significance and does not experience them as punitive. Maintenance of boundaries is also important for therapist self-care; while this is always the case it is especially so in the demanding work of complex trauma.
19. Engage in collaborative care as appropriate
This entails collaboration not only with the client, but with the other professionals and services (e.g. prescribing physician) with which they may be in contact.
20. Facilitate continuity of care as appropriate
Histories of betrayal and abandonment render complex trauma clients vulnerable to feelings of rejection. The ending of therapy (for whatever reason) is itself a process which represents `a critical opportunity to support and sustain the client’s gains in relational, emotional, and behavioural self-regulation’ (Kinsler, Courtois & Frankel, 2009) note that in the event of client engagement with a new therapist or treatment provider, interventions which encourage a sense of continuity should be integrated into the client’s transition process (Kinsler, Courtois & Frankel,2009).
21. Diversity of clients means that recovery, too, is diverse
`Therapists must be aware of differences in clients’ capacities to engage in therapy and to resolve their symptoms and distress. There are as many degrees of self- and relational impairment as there are of healing capacities and resources, resulting in different degrees and types of resolution and recovery’ (Courtois, Ford & Cloitre, 2009).