As a seasoned trauma therapist and survivor, I’ve encountered folks throughout the years who unwittingly engaged in treatment modalities that did not address their specific needs as complex trauma survivors. While some degree of helpful insight and regulation resulted from these efforts, the possibility of thriving was thwarted by not receiving the proper care.
Although humbly and honestly recognizing the parameters of one’s skill set and area of expertise is a crucial responsibility for all healthcare practitioners, unfortunately, that responsibility is not always upheld. All the more reason why a psychotherapy consumer needs to grasp that a ‘one size fits all’ treatment philosophy is not the panacea. In fact, it can be a recipe for disaster.
Given the extensive nature of complex trauma, comprehensive therapy that considers the needs of the whole person is essential. It’s important for the psychotherapy consumer to understand that simply regurgitating traumatic memories in the presence of a clinician does not constitute complex trauma treatment.
With that in mind, a while back I wrote about how to go about selecting a clinician versed in treating trauma incurred from narcissistic abuse. In that same spirit, I hope to offer a blueprint for vetting a therapist equipped to responsibly treat complex trauma, aka complex PTSD.
As opposed to a single acute traumatic episode, complex PTSD pertains to continuous assaults on one’s personal integrity and sense of safety. Ongoing or repeated interpersonal abuse (emotional, sexual, physical, neglect, abandonment, domestic violence) over which the child or adult has little or no control, and from which there is no real or perceived hope of escape, results in developmental disasters, persistent dysregulation, intimacy disorders, somatic distress, a nihilistic worldview and co-morbidity such as dissociative and addictive disorders.
Needless to say, who you entrust with your mental health should not be a shot in the dark, especially when grappling with a serious psychological disorder such as complex trauma. Choosing a clinician who will be functioning as a trusted ‘witness’ is a vital consideration, as the strength of the therapeutic bond is a primary measure of a successful treatment outcome.
In the search for a trauma therapist, you will encounter mental health practitioners with a professional suffix such as LCSW, Ph.D./Psy.D., and M.D. These clinicians maintain specific standards for training and credentialing and ascribe to shared and exclusive approaches and orientations. All these disciplines are subject to ethical principles that are enforced through board certification standards.
However, what is most important for the complex trauma survivor to determine is that irrespective of professional discipline, the therapist one chooses to work with needs to operate from a psychodynamic trauma-informed framework. This means that the vast impact traumatic injuries have on the mind, body and spirit are central to the trajectory of the work.
Establishing that you are conferring with a therapist who specializes in treating complex trauma begins with inquiring about the trauma framework and the ancillary techniques and resources employed to specifically address trauma-induced pathology. Inquiring about the types of methods, techniques and resources a clinician weaves into the trauma therapy treatment process is a relevant indicator of their expertise.
The inclusion of an array of techniques and ancillary resources is integral to trauma treatment. This can run the gamut from psychopharmacology, bodywork, art therapy, DBT, EMDR, hypnosis, bibliotherapy, somatic experiencing, group therapy and 12-step support.
Moreover, inquiring about policies that delineate the therapeutic frame, meaning the contractual ground rules, expectations, and guidelines that inform the nature of the work and the client-therapist relationship, will assist with clarifying if what is expected matches what you are ready and willing to commit to.
A trauma therapist understands that clear guidelines, and clarity about the procedures governing the work and the relationship, allows for intimate authentic disclosure to safely happen.
Accordingly, since the structure of the frame in complex trauma therapy is designed to foster a corrective attachment of vulnerable sharing, clear boundaries, relational guidelines and policies regarding consistency and accountability are immediately addressed. The structure of trauma therapy tends to be explicit and secure so as to create a safe holding environment in which the client can be ‘held’.
With pre-requisite conditions agreed upon, an initial consultation can occur. During this session, a comprehensive interview known as a psychosocial assessment is facilitated by the therapist. Information is gleaned about the client’s life, strengths and supports. Also integral to this process is reviewing the key traumas that have contributed to the inception of complex trauma. In some instances, the trauma therapist might administer the ten-question ACES quiz to quickly assess the severity of the trauma.
This thorough gathering of information allows the clinician to evaluate if you are indeed a candidate for the type of therapy they offer. If it turns out you require a higher level of care or a different type of treatment, they will discuss that with you and assist with a referral.
Similarly, you will be figuring out if this is the person you want to take this journey with. Pay attention to the therapist’s style. Do you prefer a therapist who is interactive and engaged or a therapist who is more neutral and detached? Does the therapist respond satisfactorily to questions you have regarding their clinical training and experience, treatment expectations, or other concerns? Most importantly, do you feel comfortable with this person? Do you feel understood? When navigating questions pertaining to traumatic events are you carefully guided through any activation that might ensue?
Keep in mind that you have the right to ask the therapist to explain what the treatment plan will look like. Discerning if this path of treatment resonates with you is key to knowing if this is the person who should be facilitating your healing and growth.
By the end of the consultation, you will either know or need more time to reflect on whether you want to move forward with ongoing sessions.
Knowing what to anticipate from therapy designed to heal complex trauma gives one the foresight to determine if what is happening in sessions aligns with the guidelines of trauma treatment. Hence, it's useful to recognize that rather than veer away from traumatic material, the trauma-informed therapist is committed to naming the traumas and collaboratively cultivating the resources and skills that will provide resiliency with safely processing traumatic memories. In keeping with this intention, extensive psycho-education and resourcing will occur.
Resourcing is a term which connotes returning the activated autonomic nervous system to a state of calm. The trauma informed therapist will collaborate with identifying invaluable tools needed to navigate traumatic memories and offset debilitating symptoms.
With a solid understanding of complex trauma and a foundation of self-care, the effective assembling of a cohesive narrative of one’s traumatic history can occur. The pace of processing and integrating traumatic material will largely depend on the client’s constitution and their willingness to utilize strategies and supports that assist with regulation and containment. This prolonged process of reliving and reframing all that one has endured assists with navigating complicated bereavement so that ultimately the traumas of the past can be differentiated from the present.
It’s critical to bear in mind that the treatment process is not linear. Relapses and activation occur even with a foundation of safety, stability and trust. The unearthing of profoundly traumatic material will ignite symptomatology. Hence, the complex trauma survivor and therapist need to collaboratively determine the rhythm of pacing with regard to encouraging catharsis or emotional regulation. This is a crucial matter with effectively processing material that can potentially lead to episodic decompensation.
Decompensation is most likely to occur during the stage of complicated bereavement, also referred to as Remembrance and Mourning by Dr. Judith Herman. During this stage, losses are mourned and concomitant trapped grief and rage emerge. A psychoanalytic term for this experience is abreaction, a state of purging repressed traumatic emotional material.
Questioning how a potential trauma therapist handles episodes of abreaction is a useful way of gauging their efficacy. It also reassures the complex trauma survivor that decompensation is anticipated and will be responsibly managed and addressed.
Naturally many survivors of complex trauma, frustrated by what feels like interminable regurgitating of painful themes and the exacerbation of debilitating symptoms, may bolt from therapy. As one would expect, those who stay the course and are willing to endure the repercussions of grieving a lifetime of tangible and abstract losses, need to be safely monitored. This challenging part of the treatment process may warrant the inclusion of ancillary resources such as medication management or even hospitalization.
Effective pacing and leading necessitates accessing the resources established in the initial stage of treatment. Basic fundamental tools that facilitated safety and stabilization early on, are invaluable as deeper work is approached.
Since complex trauma is rooted in extensive attachment injuries, the inevitable consummation of the therapeutic process requires its own stage of healing and growth. For many trauma therapists such as myself, the client’s participation in what is formally known as termination is a precondition for returning to therapy in the future. The intention of this requirement is to curtail the client’s impulse to bypass powerful feelings that accompany endings, as avoiding the final phase of therapy derails the full benefit of treatment.
As we all know it is never easy saying goodbye. We often bolt from such ordeals. The feelings of loss, of gratitude, of love can be just as overwhelming and anxiety-provoking as the anger, guilt, and grief that accompanies difficult endings. Yet here is where the depth of the therapeutic bond is most tested. Here is where the client and therapist fully honor what was shared and achieved.
Hence, the emphasis on responsibly engaging in therapeutic closure is in the interest of providing an invaluable reparative and corrective experience. For the complex trauma survivor who has been abruptly abandoned, blindsided by betrayal and callously discarded, staying the course to honor another and be honored is fraught with profound life-changing meaning.
When a relationally traumatized client engages in a therapeutic process with a clinician who offers the opportunity for corrective meaningful connection, healing happens. In the context of such a relationship, traumas can be effectively processed and critical relational milestones can be achieved.
For the complex trauma survivor whose life was decimated by inhumanity, the steadfast and principled emotional investment of a caring and capable trauma therapist serves as an inspired frame of reference. It is this tenacious bond characterized by deep humanity and compassion that ultimately fuels healing in the therapeutic process.