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" The overarching principle of a therapeutic relationship is that therapists should be ever mindful of a variant of the Hippocratic oath and, to the degree possible, strive to "do no more harm" (Courtois, 2010). Complex trauma clients have already experienced considerable harm, much of it at the hands of other human beings. As a result of the ubiquitous processes of transference, attachment styles, and IWM [Internal working models], these clients often view the therapist's behavior and their relationship through the lens of their trauma-related negative interpersonal expectancies and unhealed emotional wounds and injuries. Therapists should not be surprised to be "guilty until proven innocent", not because clients with complex trauma histories are "unfair" or "unreasonable" but precisely the opposite - because the most realistic self-protective stance for them (given the fact that betrayal and harm have been more the rule than the exception) is to "distrust first and verify" (or to be hypervigilant) rather than to start with an expectation of safety and trustworthiness. "
― , Treatment of Complex Trauma: A Sequenced, Relationship-Based Approach
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" Therapy must begin with empathy - not a patronizing sympathy, but instead one that is unflinching (Marotta, 2003). Empathy of this sort is highly attuned to the client, no matter the circumstance. The therapist strives to "travel in the client's shoes" or to "view the world from the client's perspective" in order to really understand his or her emotions, cognitions, and beliefs - in short, to understand from the perspective of the other (Wilson & Thomas, 2004). Treatment involves understanding that a client's defeatist and apparently helpless, disempowered, or "masochistic" perspectives can be a logical outgrowth of formative traumatic experiences and, further, may be highly creative means of self-protection. The therapist must not attempt to undo or "make up for" past abandonment or betrayals by their client's caregivers or in their close relationships, but instead first understand the client's perspective and approach to the world, while working to provide alternative perspectives on both past and present that promote change. "
― , Treatment of Complex Trauma: A Sequenced, Relationship-Based Approach
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" Kaffman (2009) described childhood victimization as a "silent epidemic", and Finkelhor, Turner, Ormrod, and Hamby (2010) reported that children are the most traumatized class of humans around the globe. The findings of these researchers are at odds with the view that children have protected status in most families, societies, and cultures. Instead, Finkelhor reports that children are prime targets and highly vulnerable, due principally to their small size, their physical and emotional immaturity with its associated lack of control, power and resources; and their related dependency on caregivers. They are subjected to many forms of exploitation on an ongoing basis, imposed on them by individuals with greater power, strength, knowledge, and resources, many of whom are, paradoxically and tragically, responsible for their care and welfare. These traumas are interpersonal in nature and involve personal transgression, violation and exploitation of the child by those who rely on the child's lesser physical abilities, innocence, and immaturity to intimidate, bully, confuse, blackmail, exploit, or otherwise coerce.
In the worst-case scenario, a parent or other significant caregiver directly and repeatedly abuses a child or does not respond to or protect a child or other vulnerable individual who is being abused and mistreated and isolates the child from others through threats or with direct violence. Consequently, such an abusive, nonprotective, or malevolently exploitative circumstance (Chefetz has coined the term "attack-ment" to describe these dynamics) has a profound impact on victim's ability to trust others. It also affects the victim's identity and self-concept, usually in negative ways that include self-hatred, low self-worth, and lack of self-confidence. As a result, both relationships, and the individual's sense of self and internal states (feelings, thoughts, and perceptions) can become sources of fear, despair, rage, or other extreme dysphoria or numbed and dissociated reactions. This state of alienation from self and others is further exacerbated when the occurrence of abuse or other victimization involves betrayal and is repeated and becomes chronic, in the process leading the victim to remain in a state of either hyperarousal/anticipation/hypervigilance or hypoarousal/numbing (or to alternate between these two states) and to develop strong protective mechanisms, such as dissociation, in order to endure recurrences. When these additional victimizations recur, they unfortunately tend to escalate in severity and intrusiveness over time, causing additional traumatization (Duckworth & Follette, 2011).
In many cases of child maltreatment, emotional or psychological coercion and the use of the adult's authority and dominant power rather than physical force or violence is the fulcrum and weapon used against the child; however, force and violence are common in some settings and in some forms of abuse (sometimes in conjunction with extreme isolation and drugging of the child), as they are used to further control or terrorize the victim into submission. The use of force and violence is more commonplace and prevalent in some families, communities, religions, cultural/ethnic groups, and societies based on the views and values about adult prerogatives with children that are espoused. They may also be based on the sociopathy of the perpetrators. "
― , Treatment of Complex Trauma: A Sequenced, Relationship-Based Approach
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" Trust of others is in short supply for many adult survivors, as complex trauma generally involves major relational betrayal. It is, therefore, expectable (although paradoxical) that clients with these histories are predisposed to be mistrustful at the outset of therapy, precisely because of (and in proportion to) the actual trustworthiness of the therapist. When past experiences have thought hard lessons, namely, that one can least afford to trust the people who should be most trustworthy, it stands to reason that confusion about trust results. The therapist must understand and not take offense either personally or professionally and not react judgmentally or defensively. Practically speaking, this involves the therapist being prepared to patiently and empathically respond to active or passive tests or challenges to trustworthiness as legitimate and meaningful communication that deserves a respectful reply in action as well as in words. "
― , Treatment of Complex Trauma: A Sequenced, Relationship-Based Approach
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" ... every therapist must develop enough personal maturity, clinical wisdom, and capacity for good judgment to effectively and safely conduct psychotherapy, an imperative that is especially important in the treatment of this population. The emotion dysregulation and insecure and disorganized attachment of complex trauma clients elicit strong emotional reactions from others, even those in their support network, including therapists. Reactions can range from sympathy, sorrow, fear, and guilt to frustration, impatience, anger/rage, hostility, and disgust or contempt. "
― , Treatment of Complex Trauma: A Sequenced, Relationship-Based Approach
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" With regard to complex trauma survivors, self-determination and autonomy require that the therapist treat each client as the "authority" in determining the meaning and interpretation of his or her personal life history, including (but not limited to) traumatic experiences (Harvey, 1996). Therapists can inadvertently misappropriate the client's authority over the meaning and significance of her or his memories (and associated symptoms, such as intrusive reexperiencing or dissociative flashbacks) by suggesting specific "expert" interpretations of the memories or symptoms. Clients who feel profoundly abandoned by key caregivers may appear deeply grateful for such interpretations and pronouncements by their therapists, because they can fulfill a deep longing for a substitute parent who makes sense of the world or takes care of them. However, this delegation of authority to the therapist can backfire if the client cannot, or does not, take ownership of her or his own memories or life story by determining their personal meaning.Moreover, the client can be trapped in a stance of avoidance because trauma memories are never experienced, processed, and put to rest. Helping a client to develop a core sense of relational security and the capacity to regulate (and recover from) extreme hyper- or hypoarousal is essential if the client is to achieve a self-determined and autonomous approach to defining the meaning and impact of trauma memories, a crucial goal of posttraumatic therapy. "
― , Treatment of Complex Trauma: A Sequenced, Relationship-Based Approach
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" Many survivors of relational and other forms of early life trauma are deeply troubled and often struggle with feelings of anger, grief, alienation, distrust, confusion, low self-esteem, loneliness, shame, and self-loathing. They seem to be prisoners of their emotions, alternating between being flooded by intense emotional and physiological distress related to the trauma or its consequences and being detached and unable to express or feel any emotion at all - alternations that are the signature posttraumatic pattern. These occur alongside or in conjunction with other common reactions and symptoms (e.g., depression, anxiety, and low self-esteem) and their secondary manifestations. Those with complex trauma histories often have diffuse identity issues and feel like outsiders, different from other people, whom they somehow can't seem to get along with, fit in with, or get close to, even when they try. Moreover, they often feel a sense of personal contamination and that no one understands or can help them. Quite frequently and unfortunately, both they and other people (including the professionals they turn to for help) do misunderstand them, devalue their strengths, or view their survival adaptations through a lens of pathology (e.g., seeing them as "demanding", "overdependent and needy", "aggressive", or as having borderline personality).
Yet, despite all, many individuals with these histories display a remarkable capacity for resilience, a sense of morality and empathy for others, spirituality, and perseverance that are highly admirable under the circumstances and that create a strong capacity for survival. Three broad categories of survivorship, with much overlap between them, can be discerned:
1. Those who have successfully overcome their past and whose lives are healthy and satisfying. Often, individuals in this group have had reparative experiences within relationships that helped them to cope successfully.
2. Those whose lives are interrupted by recurring posttraumatic reactions (often in response to life events and experiences) that periodically hijack them and their functioning for various periods of time.
3. Those whose lives are impaired on an ongoing basis and who live in a condition of posttraumatic decline, even to the point of death, due to compromised medical and mental health status or as victims of suicide of community violence, including homicide. "
― , Treatment of Complex Trauma: A Sequenced, Relationship-Based Approach
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" The act of consciously and purposefully paying attention to symptoms and their antecedents and consequences makes the symptoms more an objective target for thoughtful observation than an intolerable source of subjective anxiety, dysphoria, and frustration. In ACT, the act of accepting the symptoms as an expectable feature of a disorder or illness, has been shown to be associated with relief rather than increased distress (Hayes et al., 2006). From a traumatic stress perspective, any symptom can be reframed as an understandable, albeit unpleasant and difficult to cope with, reaction or survival skill (Ford, 2009b, 2009c). In this way, monitoring symptoms and their environmental or experiential/body state "triggers" can enhance client's willingness and ability to reflectively observe them without feeling overwhelmed, terrified, or powerless. This is not only beneficial for personal and life stabilization but is also essential to the successful processing of traumatic events and reactions that occur in the next phase of therapy (Ford & Russo, 2006). "
― , Treatment of Complex Trauma: A Sequenced, Relationship-Based Approach
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" ... as Herman (1992b) cogently noted two decades ago, these personality disorders can be iatrogenic, causing harm to individuals as an inadvertent result of the social stigma they carry and the widespread (but not entirely accurate) belief among professionals and insurers that those with Cluster B personality disorders (especially borderline personality disorder[BPD]) cannot be treated successfully, cannot recover, and are a headache to practitioners. For example, the BPD diagnosis continues to be applied predominantly to women often, but not always, in a negative way, usually signifying that they are irrational and beyond help. Describing posttraumatic symptoms as a personality disorder not only can be demoralizing for the client due to its connotation that something is defective with his or her core self (i.e., personality) but also may misdirect the therapist by implying that the patient's core personality should be the focus of treatment rather than trauma-related adaptations that affect but are distinct from the core self. In this way, both therapists and their clients may overlook personality strengths and capacities that are healthy and sources of resilience that can be a basis for building on and enhancing (rather than "fixing" or remaking) the patient's core self and personality. "
― , Treatment of Complex Trauma: A Sequenced, Relationship-Based Approach
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" Thus polyvictimization or complex trauma are "developmentally adverse interpersonal traumas" (Ford, 2005) because they place the victim at risk not only for recurrent stress and psychophysiological arousal (e.g., PTSD, other anxiety disorders, depression) but also for interruptions and breakdowns in healthy psychobiological, psychological, and social development. Complex trauma not only involves shock, fear, terror, or powerlessness (either short or long term) but also, more fundamentally, constitutes a violation of the immature self and the challenge to the development of a positive and secure self, as major psychic energy is directed toward survival and defense rather than toward learning and personal development (Ford, 2009b, 2009c). Moreover, it may influence the brain's very development, structure, and functioning in both the short and long term (Lanius et al., 2010; Schore, 2009).
Complex trauma often forces the child victim to substitute automatic survival tactics for adaptive self-regulation, starting at the most basic level of physical reactions (e.g., intense states of hyperarousal/agitation or hypoarousal/immobility) and behavioral (e.g., aggressive or passive/avoidant responses) that can become so automatic and habitual that the child's emotional and cognitive development are derailed or distorted. What is more, self-integrity is profoundly shaken, as the child victim incorporates the "lessons of abuse" into a view of him or herself as bad, inadequate, disgusting, contaminated and deserving of mistreatment and neglect. Such misattributions and related schema about self and others are some of the most common and robust cognitive and assumptive consequences of chronic childhood abuse (as well as other forms of interpersonal trauma) and are especially debilitating to healthy development and relationships (Cole & Putnam, 1992; McCann & Pearlman, 1992). Because the violation occurs in an interpersonal context that carries profound significance for personal development, relationships become suspect and a source of threat and fear rather than of safety and nurturance.
In vulnerable children, complex trauma causes compromised attachment security, self-integrity and ultimately self-regulation. Thus it constitutes a threat not only to physical but also to psychological survival - to the development of the self and the capacity to regulate emotions (Arnold & Fisch, 2011). For example, emotional abuse by an adult caregiver that involves systematic disparagement, blame and shame of a child ("You worthless piece of s-t"; "You shouldn't have been born"; "You are the source of all of my problems"; "I should have aborted you"; "If you don't like what I tell you, you can go hang yourself") but does not involve sexual or physical violation or life threat is nevertheless psychologically damaging. Such bullying and antipathy on the part of a primary caregiver or other family members, in addition to maltreatment and role reversals that are found in many dysfunctional families, lead to severe psychobiological dysregulation and reactivity (Teicher, Samson, Polcari, & McGreenery, 2006). "
― , Treatment of Complex Trauma: A Sequenced, Relationship-Based Approach
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" The development of a working alliance is crucial because it addresses a psychic phobia associated with relationships that is common in complex trauma clients. As we discussed, when primary relationships are sources of profound disillusionment, betrayal, and emotional pain, any subsequent relationship with an authority figure who offers an emotional bond or other assistance might be met with a range of emotions, such as fear, suspicion, anger, or hopelessness on the negative end of the continuum and idealization, hope, overdependence, and entitlement on the positive. Therapy offers a compensatory relationship, albeit within a professional framework, that has differences from and restrictions not found in other relationships. On the one hand, the therapist works within professional and ethical boundaries and limitations in a role of higher status and education and is therefore somewhat unattainable for the client. On the other, the therapist's ethical and professional mandate is the welfare of the client, creating a perception of an obligation to meet the client's needs and solve his or her problems. Furthermore, the therapist is expected to both respect the client's privacy and accept emotional and behavioral difficulties without judgment, while simultaneously being entitled to ask the client about his or her most personal and distressing feelings, thoughts and experiences. Developing a sense of trust in the therapist, therefore, is both expected and fraught with inherent difficulties that are amplified by each client's unique history of betrayal trauma, loss, and relational distress. "
― , Treatment of Complex Trauma: A Sequenced, Relationship-Based Approach
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" ...some adolescent survivors describe feeling special, powerful, and sometimes entitled. This is especially true of those for whom excessive attention was part of the abuse relationship by virtue any power they held over the abuser or members of the family - especially their mothers in some cases of father-daughter incest - and of any affection or sexual pleasure they experienced. All of these feelings can coexist with self-loathing and shame or might alternate with them. Some victims experience this power as personally affirming, resulting in feelings of grandiosity, whereas others believe themselves to be malignantly powerful and defective. As children, these victims may have developed the belief that they could willfully manipulate others and "make or break" the family or their peer group (or the broader community setting) with their terrible powers or the secrets they hold. In adolescence these largely implicit ideas no longer manifest mainly or only as the egocentrism associated with early childhood. A more pervasive form of narcissistic entitlement and power and an apparently callous indifference to and contempt for others can lead to conduct disturbances and the victimization of others. Many individuals with apparent sociopathic tendencies and conduct disorders were victimized as children. Such individuals at some point had the capacity for respect, empathy, and genuine social responsibility that was lost and corrupted in the struggle to survive, to make sense of, and to remove themselves from the receiving end of victimization. Identification with the perpetrator and the victimization of others is specifically included as a core feature of complex PTSD. "
― , Treatment of Complex Trauma: A Sequenced, Relationship-Based Approach
