The impacts of complex trauma are more extensive and debilitating than the symptoms of PTSD alone (Courtois & Ford, 2009; van der Kolk, 2003). While survivors of complex trauma may experience PTSD symptoms as well and are also at increased risk of PTSD, many experience a greater variety and breadth of adverse impacts. These differences demand differences in treatment (van der Kolk, 2003; Courtois & Ford, 2009).
`[t]here is no one perfect trauma therapy’ (Shapiro, 2010:1). All modalities used in treating complex trauma should include core common features which reflect the relevant clinical and neurobiological insights. There is now widespread recommendation that effective trauma therapy needs to be `bottom up’ as well as `top down’ (i.e. involve all dimensions of the person; physiological and somatic as well as affective and cognitive (Ogden, 2006; van der Kolk, 2010; Fosha, 2003). `[i]t is important to be able to engage the relevant neurobiological processes’(Fosha, 2003:229) and that `[e]ffective therapy for trauma involves the facilitation of neural integration’ (Solomon & Siegel, 2003:xviii).
Specialist treatment guidelines for complex trauma endorse a phased approach to therapy, in which the first stage (safety and stabilisation) is central and foundational prior to processing of trauma (Phase 2) and integration (Phase 3; Courtois and Ford, 2009; Blue Knot Foundation (ASCA), 2012). Trauma is highly dysregulating. It impairs reflective capacity, such that consistent focus on identification and interception of thoughts prior to the ability to self-regulate and manage internal states may itself be re-traumatising. Hence the recommendation of the expert consensus treatment guidelines that therapy for complex trauma should be phased.
People who experience complex trauma `may react adversely to current, standard PTSD treatments, and that effective treatment needs to focus on self-regulatory deficits rather than `processing the trauma’ (van der Kolk (2003:173).There are substantial limits of randomised control trials and standard outcome studies as a measure of effectiveness of treatment for complex trauma (also see Ross & Halpern, 2009). In considering effective complex trauma treatment it is important to additionally consider `practice based evidence’ which considersclient and therapist input when assessing treatment effectiveness (Green & Latchford (2012); Barkham & Hardy, 2010; Duncan, Miller et al, 2010). Common factors research substantiates that treatment does not occur in a vacuum, and that a combination of factors contribute to treatment effectiveness, including the importance of the therapeutic alliance and the relational context in which therapy takes place. Irrespective of the modality deployed, therapy for complex trauma also needs to be relational.
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