Complex PTSD Treatment
As the name would suggest Complex PTSD requires a complex range of interventions. Sometimes it will be useful to talk and interpret, sometimes to stay with present moment physical sensations ... sometimes having someone listen and bear witness will be of most use.
Most interventions fall within one of three stages:
- Remembrance & Mourning
These stages are not linear but tend to be dynamic. Sometimes the focus will be on Stage 1....and sometimes Stage 3.
However, safety will need to be in the mix at all times.
Safety needs to be established both between the client and the therapist (inter-relational safety) and between the client and themselves (intra-relational safety). Without a sense of safety it will be very difficult for a client to process - reflect and think about - their traumatic experiences.
When we are frightened our 'thinking & feeling minds' shut down. This is a normal and useful strategy.
When we are terrified almost all our mind shuts down or else it splits into separate minds. This is a normal and useful strategy.
Shutting down and splitting are excellent responses to threat but get in the way of processing one's traumatic experiences.
However, one can learn how to stay present and within a window of emotional tolerance. With these skills in hand staying with an experience - remembering the trauma or processing a flashback - becomes possible.
Creating Inter-Relational Safety:
Depending on the types of interventions being used, co-developing relational safety with a therapist will take a variety of forms.
In TCTSY the focus is on noticing a physical sensation (interoception) and making body based choices, but avoids trauma processing. Often the TCTSY Facilitator will not know the client's trauma history. For some clients it is a huge relief not to have to tell their story or be identified with it.
Space is created for a client to 'be' rather than 'be interpreted'.
In MBYT there is a 'psychoeducational' component in which one learns about the mammalian response to threat. Understanding that one's individual response to trauma is normal, functional & adaptive may help foster a sense of self-esteem, agency and connection with others.
Creating Intra-Relational Safety:
Within this 'container' of inter-relational safety, a number of intra-relational skills can be practiced, namely interoception, emotion regulation, mindfulness and distress tolerance. Some skills may be more useful than others but all will require compassionate practice - we call it a yoga practice for a reason!
Developing agency and choice is fundamental to sense of intra-relational safety.
REMEMBRANCE & Mourning:
In this phase attention is devoted to reflecting and talking about the experience of trauma. Although 'remembering is not recovery' the process of sharing one's experiences may support:
- empowerment - a refusal to obey an abuser's injunctions of silence
- freedom - a dismantling & dissolving of the silencing grip of shame, guilt & fear
- relationships - piercing the isolation of an unspoken/unspeakable life
- emotional release & comfort - emotions are meant to be felt, expressed and elicit a response; traumatised people are often denied this basic human right
- making sense of oneself - piecing together one's trauma informed historical narrative is an important step in establishing a consistent, comprehensible and stable sense of 'self'
- compassion - re-framing one's experiences from the perspective of a compassionate and trauma informed adult (this may at first be the therapist but might later be the client themselves)
- agency, free will and choice - the 'safety & stability skills' from Stage 1 will equip clients to exercise choice in their responses to trauma memories.
This phase will undoubtedly elicit strong and difficult feelings, including grief. Phase 1 work will be in regular use during Phase 2.
Phase 1 and 2 work is oriented to surviving effects of the past. Phase 3 work is oriented to building a future.
The emotional content of this phase - hope, creativity, curiosity, playfulness, peace - will often throw into sharp relief the experiences of the past, and with this, grief. Phase 3 work leaves space for grieving.
In addition a life dominated by survival may not have offered the social, financial, educational & professional opportunities that most others take for granted.
Phase 3 work will support the client whilst they explore a more mainstream life & identity.
Transitioning into a life in which trauma is an aspect of one's past as opposed to dominating one's present can be a daunting and disorienting process. The skills, strengths, insights & relationships gained in Phase 1 & 2 will play a large part in this re-adjustment process.