There is Hope: Understanding the Nature of the Treatment for Complex Post-Traumatic Stress Disorder
In this set of articles posted in November, we have been exploring several topics related to Complex Post-Traumatic Stress Disorder (CPTSD) and Adverse Childhood Experiences (ACEs). We have examined how ACEs change our brain structure, cause mental health issues and how they relate to CPTSD.
All these “negatives” may have left you feeling despair or even fear. However, in this article, we are going to explore the treatment options available today and how these treatment options can change the life of someone who is experiencing the effects of CPTSD.
Progress is Continuing There has been much progress made in this past decade about ACEs and the treatment of CPTSD.
When I began treatment in 1990, we were just beginning to see how childhood maltreatment caused damage which was not solely to the brain, we were also learning of the physical damages, as well.
With the advent of magnetic resonance imaging (MRI), scientists were able to image the brain differently than ever before. The first people researchers thought of placing in their new machines were veterans from the Vietnam War who were suffering from post-traumatic stress disorder (PTSD). What these scientists saw revolutionized psychiatry and our understanding of the damage done by experiencing severely traumatizing events.
The scientists could see that some of the structures of the Veterans’ brains had been made smaller by the fight/flight/freeze hormones humans use to escape from danger.
It wasn’t long before they began to place people with other stress-related mental disorders into the machines as well. There, before the eyes of the researchers, lay the evidence needed. They found that people who had experienced trauma in childhood had brains which had not developed correctly causing a host of psychiatric symptoms.
A Recap on the Effects of ACEs Let us now recap what we have learned so far about CPTSD and ACEs so we can see how the treatments mentioned later can help.
In article one, we examined the definition of complex post-traumatic stress disorder and how it relates to adverse childhood experiences. We looked in-depth at ACEs to see what adverse effects they can have on the formation of our personalities.
Article two focused on the brain changes which occur in children who are constantly under the stresses involved with surviving childhood trauma. We discovered the hormones generally associated with keeping our bodies ready to fight/freeze and flee are harmful to a child’s brain if the child’s brain is never allowed to return to baseline.
Some of the essential portions of the brain which are affected by ACEs are the corpus callosum, the prefrontal cortex, and the limbic system.
The corpus callosum is the wiring which connects the two hemispheres of the brain. With this wiring damaged by stress hormones, the brain cannot develop healthy communication within the brain structures. This damage leads to impairment of the child’s coordinating learning, gaining healthy self-control and many other vital areas of their development.
Damage to the prefrontal cortex means the child’s brain is incapable of completing healthy development and leads to impairments in attention, memory, and regulation of their behavior. Damage to this region can also have significant changes in the child’s ability to form their personality.
The limbic system of the child’s brain also is incapable of normally forming when exposed to the hormones released during childhood trauma. This vital region of the brain includes the amygdala and the hippocampus. The amygdala is a structure responsible for the response to—and memory of—fear, while the hippocampus is important for the consolidation and correct filing away of memories with their corresponding emotions.
Both structures will not grow to their full size and are significantly affected in these children when they reach adulthood.
Damage to the amygdala leaves adult survivors of ACEs with a brain which is constantly on high-alert and responding to danger when there is none.
Damage to the hippocampus leaves adult survivors having trouble consolidating new memories and also leaves them with triggers which can send the survivor into debilitating flashbacks.
While the damages done to the brain in childhood are permanent, this does not mean a survivor cannot learn ways to mitigate how the damage affects them as adults. We will discuss treatment in today’s article which can be transformational for adult survivors of ACEs.
In the third article, we examined the emotional problems and disorders which are common among those who have experienced adverse childhood experiences.
Trauma-Informed Care Today CPTSD is recognized as needing long-term treatment because of the damages done to a person’s self-identity, deficits in self-regulation and their inability to see there is hope and healing available to them. Fear and hopelessness can be a daily reality for most survivors living with CPTSD symptoms. Therapists choosing to work with patients living with CPTSD symptoms must take the time to receive the education they need to provide trauma-informed care.
Additionally, they will need to understand that with the resolution of one issue—there will come others popping up seemingly out of nowhere. This is the nature of CPTSD.
The understanding of the day-to-day difficulties patients face while living with complex post-traumatic stress disorder is a necessary part of trauma-informed care. Patience and unconditional warm regard are key if we are ever to help anyone have the hope they need to heal. Trauma-informed care is an approach which sprang from the Substance Abuse and Mental Health Administration (SAMHSA), and its recognition of trauma is a significant role in the formation of women’s issues and gender-specific treatments in the 1990s. Over the next two decades, a lot was learned about diagnosing post-traumatic stress disorder and the diagnostic criteria and treatments for it.
The core ideas for trauma-informed care started to take shape and spread during the ACEs study mentioned in previous articles, as well as the launching of the Women, Co-Occurring Disorders and Violence Study in 1998 which was sponsored by SAMHSA. This study began the search for plans to help women who were victims of trauma and who also had co-occurring diagnoses of mental health disorders and substance abuse disorders.
The researchers recommended for “trauma-integrated services counseling” which has morphed into trauma-informed care today.
Trauma-Informed Care: The Basics To save time and get to where we learn about the different forms of therapy used to treat CPSTD, I’m only briefly going to touch on the different goals of trauma-informed care. In future articles, we will discuss this subject in much more depth.
There are six basic aspects a trauma-informed therapist works towards; these include forming a therapeutic alliance, guiding you away from certain topics, helping you to understand where your behaviors and symptoms stem from, setting recovery as the goal for treatment, focusing on your strengths rather than your illness, and learning resiliency.
The first goal is covered extensively toward the bottom of this article, so we will discuss these aspects out of order.
Guiding You Away from Certain Topics.
Your therapist will do their best to guide you away from topics charged with emotions. At first glance, this step may seem counterproductive. Isn’t tackling the issues which drove you to therapy the most crucial part of your recovery? However, a therapist trained in trauma-informed care understands you must first learn to cope with the inevitable pain which will come up while working on your past before you may safely face it.
Helping You Understand Where Your Behaviors and Symptoms Stem From.
Trauma-informed therapists know unhealthy coping mechanisms, like shutting down in sessions and dissociation, are coping mechanisms which stem from your adverse childhood experiences. Trauma-informed therapists help you to understand these are indeed coping strategies you have used and may still use, to deal with your overwhelming emotional pain.
Trauma-informed practitioners will also make a significant statement to you, that at first, you may not accept: “What happened to you so long ago was never and shall never be your fault. You were a victim. However, now that you have achieved adulthood you and only you are responsible for your life today.” Adult survivors of adverse childhood experiences have a very difficult time believing they are not to blame for their trauma and abuse.
Setting Recovery as a Goal for Treatment.
Although co-occuring problems may exist, it is vital for your trauma-informed therapist to help you understand they will get better as you work through what happened in your past. The other symptoms or disorders, such as depression and anxiety, are not the overarching concerns, but rather effects from working on your recovery from complex post-traumatic stress disorder.
Focusing on Your Strengths Rather Than Your Illness.
Many skills can be learned to cope with childhood trauma, and a trauma-informed therapist will work with you to use them. Your therapist may ask you questions to help you think and keep focused on the future such as, “What are some of your accomplishments which make you feel proud?” By using positive language, your therapist will help you recognize you are capable of coping well even with tough experiences.
Resiliency’s best described as the ability to overcome challenges of all types—including tragedy and personal crises—and bounce back stronger than before. Most of us who have survived childhood trauma are already very resilient. However, we often overreact or do not respond appropriately when faced with problems in our adult lives. Your trauma-informed therapist can help you understand some fundamental concepts such as how life is not fair, or how life is not easy. Once you have these lessons under your belt, events such as life changes, struggles, and death take on a new perspective, as they are just parts of life which all humans share.
The Importance of Establishing the Therapeutic Alliance For we who were victimized in childhood and did not have a chance to establish a safe-base with someone we trust, beginning to see a therapist feels very risky. The bond which forms between our therapists and us forms a connection where they can engage with us and help us to recognize our old behaviors and learn new ones.
This relationship is called the therapeutic alliance, and it isn’t one-sided or static. This relationship with your trauma-informed practitioner will be reciprocal—in fact, it is worth noting, a hallmark sign of all healthy relationships is reciprocity. This is not to say all relationships which have reciprocity are safe and healthy relationships, however, any relationship lacking reciprocity is worth looking at closely and determining whether or not it is safe or healthy.
It is also worth noting, therapists are humans too and can become emotionally attached to their clients. To help themselves, therapists must practice excellent self-care, such as setting healthy boundaries and taking ample time off from work for vacations. Therapists, like all humans, have flaws, but they can find ways to use those flaws to help us understand our recovery journey and to connect with us.
As the relationship between you and your therapist goes on, it will change and not remain static.
At first, you may feel uncomfortable and unable to share your feelings. However, after a bond forms and you begin to trust, you will relax into the relationship. You will then become open and honest about not just how you are feeling but you’ll also feel safer telling your therapist about any dangerous behaviors or thoughts you might be having. This is when therapy and recovery can begin.
Establishing Safety It is safe to say that a tremendous therapeutic bond is absolutely vital to anyone living with symptoms of complex post-traumatic stress disorder, especially if we are to ever face and accept the indescribable pain of what happened in childhood.
Once you feel comfortable with your therapist, it will be easier to a begin the hard work of facing what happened to you head-on, and ways you can heal.
Some of the safety issues which need to be tackled before the healing work begins are:
Self-Destructive Thoughts and Behaviors
Suicidal Thoughts and Behaviors
It is clear, all the above safety concerns can be highly re-traumatizing, and suicidal ideation/behaviors can lead to death. To mitigate these threats to life, a trauma-informed therapist must seek to replace the need for these behaviors. This happens through agreeing on a safety plan. This is always done with you.
A safety plan may include you learning how to contact your therapist if you are having problems between sessions. However, your therapist may have rules about the ways you may contact them, such as at the office only or via email.
Your therapist may also ask you to sign an agreement with them stating you will not try to die by suicide. Instead, you promise you will reach out to someone you have listed on your safety plan or agreement.
Some therapists may ask you to attend Wellness Recovery Action Plan (WRAP) classes so you can make a detailed plan of what you will do in case you find yourself in trouble and having thoughts of self harm or suicide.
I, Shirley, am going to share my personal experience with this part of the treatment I endured. My therapist, Paula, knew I was in deep trouble from the first day. Not only was I not able to remember what had driven me to her office, but I told her the reason I was there was because I was suicidal and had attempted to die by suicide twice already in my life.
Paula’s first question was if I would sign an agreement with her not to act on my suicidal impulses. I told her to her face that no, it would do no good. I would sign it, but I wouldn’t consider it something I must honor.
Paula worked hard to establish trust between her and me, knowing that if she didn’t succeed, the chances of my dying young were high. Even after working with her for almost seven years, in 1995 I took an overdose in a dissociated state which almost claimed my life.
On examination, Paula and I both understood that she had done all she could do to help me remain alive and that the only one who could keep me alive was me. We worked harder to conquer my feelings of self-destruction and today I can say that I have not tried to die by suicide for twenty-three years. I owe my life to a beautiful therapeutic alliance with Paula.
The Different Psychotherapeutic Approaches of Treatment
While there are many approaches to treating CPTSD, there are a few types of psychotherapy utilized the most.
When people visualize talk therapy, they usually conjure thoughts of a therapist sitting in a chair beside their client who is reclining on a couch beside them. While lying down and speaking to a therapist is not disallowed, it usually isn’t what happens. Instead, the therapist and client typically sit facing one another at a comfortable distance.
During talk therapy, you will talk with your therapist about a variety of topics including those which trouble you the most. Your therapist will not give you advice, nor will they give you the answers to your problems. After all, they are not living in your mind nor are they living your life. Only you understand what you want out of life, and only you can find your answers.
Instead, what a therapist does is guide you, envision if you will a seeing-eye dog. They will warn you the traffic is coming, but ultimately it is you who decides to cross the street or not.
Cognitive Behavioral Therapy (CBT).
This form of treatment involves the therapist attempting to help their client identify and change inaccurate thinking patterns which can lead to behaviors which are harmful or ineffective.
Your therapist will help you focus on the current problems in your life which were caused by adverse childhood experiences and how to resolve them today. CBT involves practicing new skills so you can function well in the world.
Dialectical Behavioral Therapy (DBT).
DBT helps you learn how to regulate emotions. This form of therapy helps teach new skills to aid you in taking personal responsibility for your behaviors and your overall health. By taking such responsibility, you become more likely to implement the changes necessary to make your life more manageable.
Sand Tray or Sand Box Therapy.
Although not as well-known as the therapies listed above, sand tray or sand box therapy isn’t just for kids; it is also an essential form of treatment for adults, as well. Sand tray therapy helps you construct a microcosm in the sand tray of your life and those connected to it using miniature toys and different colored sand. By doing this, the choices of objects you use to represent yourself and those around you help you recognize how you see yourself and resolve conflicts within you. It also helps you to gain acceptance of who you are as a human being.
For adults, sand box therapy provides emotional release and realization of traumatic events in an atmosphere free from threats. Your therapist asks you to pick objects and figurines to represent the people you are conflicted with and place them in the sand tray. Then together with your therapist, you can work to understand the reasons you chose each figurine and the positions you have placed to understand better the truth behind how you feel about the people represented and any emotions you have attached to them.
Sand box therapy can be potent, especially when you and your therapist begin to rearrange the symbols. Doing this together, suddenly gives you a deeper understanding of how you see the people in your life and allows you to feel a sense of power over them.
Another very powerful tool therapists can use is drama therapy. This type of treatment involves a specially trained therapist who understands not only how to utilize trauma therapy but also can recognize when someone is getting into emotional trouble while using it. Drama therapy is done in a group of people with whom you have been in group therapy before, and have acquired trust. The therapist will ask you to relate a scenario you have been working on in private therapy and to choose people from the group to represent the other people involved. To help you understand better how powerful drama therapy can be, I’m going to relate my last episode.
The event I chose was from when I was six-years-old, and my brother Jim was three. My father was in the Navy and had shipped out on board an aircraft carrier. Our mother was addicted to both alcohol and prescription medications and would lie on our couch passed out most of the time. Unfortunately, her condition left the two of us to fend for ourselves; only we could not because all the food in the house was locked up. This inability to feed ourselves left Jim and me desperate for food to the point where we would eat dandelions and rocks to fill our stomachs.
One day, when I was in the first grade, the school grew concerned about the state I went to school in, and asked the Navy to send some military police to check up on our mother. So, two very tall MPs bearing weapons on their sides escorted my six-year-old self home from school that day. Because I was so young, I felt terrified they were going to shoot my mommy. When we arrived, mother came to the door and after being politely asked about her welfare, told the MPs all was fine, and they left.
After choosing people to represent myself, my mom, the MPs, and Jim, we acted out the episode just as it took place in 1966. Then we did it again, only this time I, as my adult self, rescued myself and my brother from my mother and had her arrested for child neglect. Then I took myself and Jim to McDonald’s, and while they ate, I promised them they would never, ever go hungry again.
That, my friends, was one of the most powerful things I have ever done, and it taught me that I CAN rewrite my history.
I feel we have been on a real adventure of discovery together in this series of articles. One which can help us understand who we are, where we are, and how we got here.
Although the damages done to our brains and emotions are great, they need not hold us captive forever. While the trip taken in therapy is a long one, there is no reason it cannot be successful.
The brain is a marvelous and wondrous organ. Scientists once thought that when we become adults, our personalities and the traits which make them up cannot change. Now we understand, that like any other part of the body, our brains change with experience. It’s called neuroplasticity.
That fancy name only means our brains are like plastic—moldable and pliable. Even though we cannot undo the damage done to our amygdalae and hippocampi, does not mean our brain cannot adapt to new ways of coping.
The most important message I wish to leave you with today is this. YOU ARE NOT ALONE and THERE IS HOPE AND HEALING.
I truly hope you have enjoyed this series as much as I have enjoyed writing it.
Our next series, beginning the first week of December, will center around coping with the anxiety and other strong emotions brought on by Christmas and the winter holiday season.