The rapid progress in trauma-informed awareness over the last 20 years with new knowledge around the neurobiology of attachment, developmental trauma, somatic and memory processes, and subjective meaning is informing treatment responses. Frameworks of care and treatment are changing from purely bio-medically based (psychiatry) and purely psychoanalytical (psychology) models to additionally incorporate a trauma-informed psycho-social model. Contemporary approaches to complex trauma treatment are additionally drawn from psychodynamic work (Davies and Frawley, 1999; Howell and Itzkowitz, 2016),somatic work (van der Kolk, Rothschild, Levine, Fisher & Ogden et al), trauma-based dissociation (Janet, van der Hart et al, 2016) and mindfulness and Eastern principles (Briere et al). Advances in technology mean that many previous theories are now supported by investigations including MRI, blood tests, PET scans. The role of the body and its processes are the cutting edge of new understandings, as are practice based evidence and common factors research.
It is now recognized that working ‘bottom up’ and ‘top down’ engages all areas of the brain. This is needed to unite body, mind and brain, and integrate emotions, sensations, awareness and thoughts, the connections between which are often disrupted by complex trauma (Cozolino, 2006; Ogden, 2006; Siegel, 1999). Body-oriented approaches such as trauma-informed yoga and mindfulness, as well as EMDR can help the body and mind reconnect.
A number of key international bodies (ISSTD, 2011; ACPTMH, 2007; APA Div.56) and 84% of clinicians expert in treating either complex PTSD or PTSD in a survey report endorsed a phased approach (Cloitre et al., 2011).
The extensiveness of the impacts associated with complex trauma means that three phases of treatment are recommended:
(1) Stabilisation, resourcing and self-regulation
(2) Processing of traumatic memories which, because unassimilated, impede integrated functioning and quality of life
(3) Consolidation of treatment gains towards optimal re-engagement in relationships, work and life (Cloitre et al, 2011)
‘On average, this treatment is longer-term than that for less complex clinical presentations. For some clients, treatment may last for decades, whether provided continuously or episodically. For others, treatment may be quite delimited, but it rarely can be meaningful if completed in less than 10-20 sessions. Even therapeutic modalities that are designed to be completed within 20-30 sessions may require more sessions or repetitions of `cycles’, or episodes, of the intervention. Obviously, goals and duration of treatment should be geared to the client’s ability, motivation, and resources. When they are limited. Interventions are directed toward safety, support, education, specific skills and, in some cases, psychosocial rehabilitation and case management’ (Courtois et al, 2009:96). For severely impaired patients, treatment of several years may be necessary and/or may be required intermittently over the individual’s lifetime (Loewensten et al, 2014; Cloitre et al, 2011).
Therapeutic groups can also be a particularly powerful adjunctive modality for trauma survivors if patients are carefully screened for a group that matches their stage of treatment. Subject to screening and expert trauma-informed facilitation, participation in a psychotherapeutic group can foster safety, self-understanding, and reduction of isolation, shame and related cognitive distortions.