Complex Trauma; Recognition, Rehabilitation, Recovery.

 

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In the pursuit of psychological knowledge, (and GenZ’s pop-culture humour), a word we are acquainted with is ‘trauma’. As described by the American Psychological Association, trauma is an emotional response to a distressing event that can be physically or emotionally threatening. In primary terms, when referring to traumatic incidents, we picture crimes, disasters, instances of sexual/physical abuse, etc. However, with psychoeducation, we now understand that trauma is subjective; any incident that causes significant emotional and/or physical distress and pain to a person can be traumatic. The understanding of trauma can’t be cookie-cutter; given the diversity of human experiences and their impact on lives. The psychology community’s wisdom of trauma has grown with the understanding of ‘complex trauma’, a form so many people suffer, knowingly or unknowingly.

“Complex trauma is a ‘dual problem’, involving both exposure to traumatic events and the impact of this exposure on immediate long-term outcomes”, as defined by the National Child Traumatic Stress Network (NCTSN, 2003, p. 5). NCTSN further elaborates that complex trauma involves repeated experience of the same or multiple types (emotional, physical, sexual) of traumatic incidents (happening concurrently or sequentially) over a period of time[1]. First proposed by Herman in 1992 as Complex Posttraumatic Stress Disorder, it is conceptualised to be an enhanced form of PTSD, maintaining the core symptoms– re-experiencing, avoidance, and hypervigilance (van der Kolk, 2015; Cloitre et al., 2011; van der Kolk et al., 2005, as cited in O’Shea Brown, 2021). However, additional symptoms such as poor affect regulation, negative self-concept, shame-based cognition, social withdrawal, barriers in forming and maintaining healthy interpersonal relationships, severe despair, and somatisation as a result of relational and developmental trauma are not incorporated in the PTSD diagnostic criteria, setting it apart (O’Shea Brown, 2021).

Rehabilitation psychology conventionally refers to the study and application of psychological principles to help individuals suffering from chronic illnesses or injury-induced disability overcome cognitive, emotional and functional challenges (American Psychological Association, Rehabilitation Psychology 2015)[2]. In a broader sense, psychological rehabilitation involves the facilitation of overall recovery and healing to restore life adjustment, a juncture where survivors of complex trauma meet hope, and professional help.

The foundation of a comprehensive patient-oriented rehabilitation program for patients with complex trauma is Trauma-Informed Care (TIC). It encompasses the 4 R’s: realisation of the overarching impact of trauma followed by the understanding of recovery pathways, recognition of the signs and symptoms in everyone within the ecosystem along with the patient, response integrating the knowledge of trauma into practices and resistance of re-traumatisation (SAMHSA, 2014(b), p. 9 as cited in Koch et al., 2020)[3].

The Missouri Model, a developmental framework for TIC in organisations sheds light upon the five basic principles that have to be at the crux of any TIC intervention (MO Trauma Roundtable, A developmental framework for trauma-informed 2022)[4]. These principles, relevant to psychological rehabilitation of complex trauma are:

- Safety: Ensuring physical and emotional safety, recognising and responding to the patient’s racial, ethnic, religious, gender identity or sexual orientation intervention (MO Trauma Roundtable, A developmental framework for trauma-informed 2022).

- Empowerment:  Encouraging self-efficacy, identifying strengths, and building skills which lead to individual pathways for healing while recognising and responding to the impact of prolonged trauma intervention (MO Trauma Roundtable, A developmental framework for trauma-informed 2022).

-Collaboration: A dynamic of shared power and decision-making between the rehabilitators and the patients (Koch et al., 2020).

- Cultural sensitivity: The experience of complex trauma is influenced by cultural context and societal constructs, which can even cause the same (Ranjbar et al., 2020)[4]. Hence, cultural sensitivity is essential for rehabilitators to understand the subjectivity of the trauma faced by their patients.

 Reflecting these basic principles, evidence-based modalities for the treatment of Complex Trauma that clinicians must adopt for successful rehabilitation as follows:

- Trauma-Focused Cognitive Behavioural Therapy (TF-CBT): Developed by Judith Cohen, Esther Deblinger and Anthony Mannarino in the 1990s, TF-CBT combines techniques from CBT and Family Therapy (O’Shea Brown, 2021). It is adopted specifically to the needs of the patient, revolving around psychoeducation, parenting skills, affect regulation, cognitive processing of traumatic/painful material, and formulation of a trauma narrative, in addition to enhancing future safety (Cohen et al., 2004, 2005; Deblinger et al., 2006 as cited in O’Shea Brown, 2021). At first, psychoeducation can aid the survivor in processing their emotions and understanding their bodily responses to stimuli (Bisson, 2009 as cited in O’Shea Brown, 2021). It facilitates cognitive restructuring of traumatic memories, directed towards reduction of trauma-related symptoms (Lanius et al., 2010 as cited in O’Shea Brown, 2021). Using specific workbooks, the patient is first led through guided introspection to confront disturbing events, then provided with psychoeducation, exposure, cognitive restructuring, and affect management training (Harvey, Bryant, & Tarrier, 2003 as cited in O’Shea Brown, 2021). CBT techniques are also adopted to restructure maladaptive thought processes and reactivity in negative behaviours in a trauma-informed manner (O’Shea Brown, 2021).

- Eye Movement Desensitization and Reprocessing (EMDR): Developed by Francine Shapiro in the 1980s, it helps to resolve unprocessed traumatic memories in the body. Following an 8-step procedure of history-taking, preparation,  stabilisation, assessment, desensitisation, reprocessing,  closure. and re-evaluation, efforts are made to build affect tolerance (a sense of safety in the body), which is known as Resource Development and Installation (RDI). This integrated EMDR-RDI approach helps the patients restore their ability to physiologically modulate stress responses, and prepare them for active processing of traumatic memories (O’Shea Brown, 2021). Post stabilisation, the patient and client mutually decide upon ‘target memories’, which are then processed with simultaneous Bilateral Stimulation, through bilateral eye movements, tapping or auditory stimulation guided by the clinician. This helps produce a state similar to REM sleep, which supports full processing of the memories, desensitising of the associated emotions and bodily sensations, helping patients adapt and make new positive associations. (Stickgold 2002, as cited in O’Shea Brown, 2021).

- Somatic Experiencing: Complex trauma impacts the nervous system, leading to physiological hyperarousal in patients. Hence, body-oriented approaches are crucial to address the overall impact, and facilitate smoother rehabilitation when TF-CBT and EMDR feel overwhelming (Fisher, 2001; Fisher, 2019 as cited in O’Shea Brown, 2021). Developed by Peter Levine, through SE, awareness of inner physical sensations associated with traumatic memories is brought within the patient. It focuses on the residual energy from the traumatic instance that is unexpressed for a long time, thus getting internalised and causing long-term autonomic and central nervous system dysregulation. Patient’s full attention is guided to their internal sensations through self-report, which brings a sense of final release (O’Shea Brown, 2021).

Survival and rehabilitation of complex trauma is a difficult hike, both for the clinician and the patients. The approaches discussed above allow survivors to process trauma and reinstate a sense of safety. However, continuing support and research to refine existing methods and develop new ones is necessary to increase quality of care. With good quality of clinical care, mutual trust, efforts and resilience… recovery is possible. 

 

References

[1]Section 1A Review of the Literature. (n.d.). story. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK207192/#:~:text=Complex%20trauma%20is%20typically%20interpersonal,Van%20der%20Hart%2C%201996. 

[2] American Psychological Association. (2015). Rehabilitation psychology. American Psychological Association. https://www.apa.org/ed/graduate/specialize/rehabilitation

[3] Koch, M. C., Vajda, A. J., & Koch, L. C. (2020). Trauma-informed rehabilitation counseling. Journal of Applied Rehabilitation Counseling, 51(3), 192–207. https://doi.org/10.1891/jarc-d-19-00025

[4] A developmental framework for trauma-informed. Addiction Technology Transfer Centre. (2022). https://attcnetwork.org/wp-content/uploads/2019/03/The-MO-Model_A-Developmental-Framework-for-Trauma-Informed-Revised-Edition-2022.pdf 

[5] Ranjbar, N., Erb, M., Mohammad, O., & Moreno, F. A. (2020). Trauma-informed care and cultural humility in the mental health care of people from Minoritized Communities. Focus, 18(1), 8–15. https://doi.org/10.1176/appi.focus.20190027 

[6] Brown, O. (2021). Healing complex posttraumatic stress disorder O’Shea Brown. Springer International Publishing.