Introducing Issues in the Treatment of Complex PTSD

Onno van der Hart, Kathy Steele, and Julian D. Ford

Compared with the growing base of efficacy research on short-term cognitive behavioral and exposure treatments for PTSD and acute stress disorder (cf, Bryant et al., 1999; Foa et al., 2000), there is a dearth of outcome research on treatment of complex PTSD. Yet, many trauma survivors experience pervasive polysymptomatic impairments that go beyond PTSD. ISTSS recognizes the need for further clinical study and research into the etiology, diagnosis and treatment of complex PTSD. ISTSS President Bonnie Green formed the Complex Trauma Task Force (CTTF) in November 2000-consisting of John Briere, Christine Courtois, Julian Ford, Laurie Pearlman, Onno van der Hart and Bessel van der Kolk. The CTTF will make recommendations for further study of complex PTSD based upon a summary of literature that will be presented in a special issue of the Journal of Traumatic Stress. This article introduces issues in the treatment of complex PTSD.

Research documents substantial comorbidity associated with PTSD (e.g., personality, affective, anxiety, dissociative, addictive and eating disorders; Perkonigg et al., 2000). Many trauma survivors experience impairments in attachment, cognition, memory, affect regulation, self-reference and meaning (e.g., Briere, 1997; Ford, 1999; McCann & Pearlman, 1990; van der Kolk, 1996). Rather than addressing comorbidity separately, a comprehensive, individualized, evidence-based, theory-guided approach is essential to treat the sequelae of complex trauma.

The general consensus is that phase-oriented treatment is the standard of care (Brown et al., 1998). Pierre Janet proposed three phases: Phase 1) stabilization; Phase 2) resolution of traumatic memory; Phase 3) personality (re)integration and rehabilitation. However, these phases are not strictly linear but rather have been hypothesized to proceed in a spiral with frequent alternation among phases (Courtois, 1999). Throughout, therapy must be paced carefully in accordance to the tolerance of the patient, while addressing several core goals: integrating dissociated aspects of the personality; reestablishing secure attachments; building self-management skills; and developing a coherent personal narrative (cf., Brown et al., 1998; Herman, 1992; Saakvitne, Gamble, Pearlman & Lev, 2000).

Phase 1 focuses on safety. Concentration on the elimination or management of dangerous behaviors and relationships, self-harm, substance abuse and impulse dysregulation is a priority. Simultaneously, safety in the therapeutic relationship is addressed. Psychoeducation and skill-building assist the patient in achieving "internal" safety (e.g., becoming less fearful of thoughts, feelings, dissociative episodes and general distress) and in enhancing relationship, affect regulation, distress tolerance and daily living skills. Attention to and treatment of Axis I, II and III comorbidity is essential within a coherent and comprehensive treatment approach. Medications often are considered to facilitate management of severe symptoms (e.g., anxiety, depression, anger, impulsivity, insomnia; Friedman, 2000).

In Phase 2, treatment focuses on resolution of traumatic memory processing. As noted already by Janet, the phobia (i.e., extreme avoidance and fear) of traumatic memory is central in posttraumatic psychopathology (van der Hart et al., 1993). Thus, a paced and modulated approach to traumatic material is essential; otherwise the patient is likely to continue to avoid and dissociate in response to reactivation of traumatic memory. During this phase, resolution of intense and insecure attachment conflicts must be addressed, including insecure attachments to neglectful or abusive caretakers or other perpetrators. A narrative account of the trauma must be developed without recapitulating the trauma-i.e., without inadvertent exacerbation of the primary intrusive reexperiencing symptoms. Some approaches to trauma treatment explicitly begin trauma-processing work on a graduated basis in Phase 1 and continue it through all three phases (Briere, 1997; Ford & Kidd, 1998).

Finally, in Phase 3, personality (re)integration and rehabilitation are the focus. The patient is supported in living a functional life, which often has been severely constricted due to avoidance of traumatic stimuli and the inability to adapt to and integrate a wide variety of complex experiences. Many patients struggle at this point with the capacity to tolerate change and management of the normal vicissitudes of daily life. Practice, graduated exercises, sustained mental effort and increased awareness of the (relatively) safe present are important interventions. Existential and spiritual issues often warrant therapeutic attention. Ultimately, Phase 3 treatment seeks to enhance the capacity for physical, sexual, emotional and interpersonal autonomy and intimacy.

Phase-oriented treatment models remain in the early stages of development. The specific underlying theoretical assumptions and requisite clinical techniques need to be fully explicated and carefully evaluated. For example, recent outcome research results call into question the safety, necessity and sufficiency of traditional trauma-focused "exposure" work with survivors of complex developmentally adverse trauma in Phase 2 (McDonagh-Coyle et al., 1999). The current evidence base for PTSD treatment acknowledges the importance of addressing complex sequelae, but provides little guidance (cf, Foa et al., 2000). One current attempt to sort out the impact of such factors is an expert survey, in which experienced clinicians who treat polysymptomatic patients are asked to categorize and rate the importance of complex variables in treatment. The results of this survey will be presented at the ISTSS 17th Annual Meeting in New Orleans.

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