Lack of research and exclusion of truly complex cases
Research for complex trauma and dissociation is severely underfunded relative to the numbers of individuals with these conditions. As such, there aren’t any randomized control trials that assess a specific protocol, like there are for other disorders. The few studies that claim to include survivors of complex trauma will include people who have been exposed to the traumatic events I described a couple of posts ago, but then exclude people who are suicidal, have self-harming behaviors, have comorbid disorders, have psychotic symptoms (people who are dissociative can appear to have psychotic symptoms) and/or have substance abuse. Since this describes individuals with dissociative disorders, the studies are excluding clients who have truly complex trauma. This study, for example, claims to study the efficacy of CBT and CPT, relatively short term evidence-based treatments for classic trauma. However, they exclude people with almost all of the symptoms listed above, so while the participants may have some features of complex trauma, they definitely don’t resemble the complex trauma clients that I work with, or that are described in case studies of extremely dissociative cases.
This study did show that when TF-CBT is adapted to be administered in a phase-based fashion (up to 30 sessions instead of 12, assessing for safety and stability throughout), it can be helpful in treating adolescents with complex trauma. Unfortunately, they say almost nothing about their participants except to note how difficult it is to assess youth for complex trauma, so we don’t know how severe their symptoms were when they started.
So what do we know?
What does exist are some case studies and a large, international prospective study by Bethany Brand that examines what practitioners are currently doing and assesses how that is working. The good news is that practitioners who take on complex trauma clients (the suicidal, self-harming, addicted, dissociative ones with disorganized attachment) are doing solid clinical work that is consistent with complex trauma treatment guidelines and are unequivocally helping clients get better.
What is currently recommended to treat complex trauma and dissociation is a three phase treatment approach. Incidentally, if you’re seeking a therapist for complex trauma a great way to find out if they know what they’re doing is to ask if they use this (or if they even know what it is).
Phase I- Safety and Coping
- in some cases, this phase can take months or even years
- a great deal of attention is paid to rapport to address attachment phobia
- emotion regulation and grounding are used to help the individual stay in the present and in their window of tolerance
- safety and stability for individuals who have suicidal thoughts or self-harming behaviors
- distress tolerance and coping to help
- Evidence based practices that are helpful at this stage can include DBT, mindfulness, CBT skills (including those from ACT and CPT), and Resource Development and Installation from EMDR. Also there are several group treatments that can be helpful, particularly Seeking Safety.
Phase II-Trauma Processing
- Prolonged exposure, by definition is not recommended. Instead, trauma exposure should be gradual. A significant feature of complex trauma is that clients experience frequent intrusions of the trauma, and they aren’t able to avoid it the way that many people with classic trauma can. Therefore, they are already experiencing flooded exposure to their trauma and more of that isn’t therapeutic. Instead, re-experiencing is done while within the window of tolerance and while the client has a dual awareness with the present so that they know they are safe.
- Safety and coping interlaced throughout
- May be interspersed with checkup/integrative sessions. Many of my clients experience a whole new perspective on their experience and need a session between memories to process this.
- Techniques from EMDR, somatic work, and trauma narratives from CBT exposure-based therapies listed above are effective here
- Integrates new skills, insight and stability
- Helps client develop sense of new normal
- For clients with Dissociative Identity Disorder, final integration of parts into the whole takes place