I recently heard from two former clients that they have not been successful in finding new therapists since I moved. They’ve tried new therapists, of course, but they have found that what “qualifies” the trauma therapists they’ve met is the fact that they’ve treated trauma. But doing something over and over again doesn’t mean I do it well, it just means that I’m an expert in how I’m doing it. I can practice hitting tennis balls everyday for years, but if I’ve been practicing hitting them wrong, then I’m no tennis master; I’m just really good at hitting tennis balls badly. No, only perfect practice makes perfect. Experience plus training plus good supervision is what can produce a good trauma therapist.
An article recently came out that outlined the challenges in getting that training and supervision for the treatment of child-abuse related complex PTSD. It was a quantitative review of all randomized control trials of treatment for women with child-abuse related PTSD. There isn’t much. In the last 40 years, there are only 24 randomized-control trials where over half of the participants experienced child-abuse as the traumatic event and had PTSD symptoms. Only 7 studies were completely composed of participants who had child-abuse related PTSD. Of those, only 4 studies only had participants with complex-PTSD symptoms.
Complex PTSD is not the same as PTSD
One reason for the dearth of research is that complex trauma isn’t a diagnosis in the DSM, which means that research for it is particularly difficult to fund.
The symptoms of complex trauma—difficulty with emotion regulation, dissociation, maladaptive coping such as self-harm, substance dependence and disordered eating, imply that a 3 session prep on coping prior to exposure therapy, usually considered the gold standard for PTSD treatment, may not be sufficient to establish safety and sufficient emotion regulation for trauma processing. The article confirms that exposure therapy is not as effective for complex trauma as affect management therapy.
Study Participants: Healthier Than You!
In the 7 studies which evaluated effective treatments for people with child-abuse related PTSD, many participants with complex-PTSD features were excluded from participation, including women with:
- organic brain disorder
- psychotic disorder (excluded from 6 studies)
- substance abuse or dependence (excluded from all 7)
- one study only excluded individuals if the substance abuse interfered with treatment compliance
- suicidality (excluded from 5 studies)
- One excluded suicidality only if it required referral to a hospital
- The two studies with populations diagnosed with Complex PTSD did not exclude suicidalit
- dissociative disorders (excluded from 4 studies)
- eating disorders (excluded from 2 studies)
- bipolar disorders (excluded from 3 studies)
- borderline personality disorder (excluded from 2 studies)
- Another study included personality disorders, but then excluded severe borderline personality disorder
- ongoing abuse (excluded from 2 studies)
Basically, we need research that includes clients that look like clients that show up in therapy. Clinicians who treat complex trauma aren’t “excluding” clients because they’re suicidal or using substances or have borderline personality traits, and most complex trauma clients have at least a couple of these behaviors. Yet we’re supposed to rely on empirical research to guide our treatment. How can we when it’s so limited and trial participants don’t look anything like our clients?