Essential Guide to Complex Trauma Therapy: C-PTSD Treatment, Pacing & Therapist Preparedness

When considering working with a client who has complex trauma, clinicians need to consider if they have the skills to work with these clients and also the necessary space for them in their practice.

Treating complex trauma is nuanced. It requires extensive training, compassion, and self-awareness. It also calls for a clinician to listen to explicit material, which they must be able to hold and compartmentalize.

Here are several considerations every therapist should consider before working with complex trauma.

Attachment development and/or erotic transference

This can scare some clinicians. However, it’s important to understand what is actually occurring for many people when they report or hint at these experiences. Attachment occurs much of the time when a person has a history of neglect and has suffered deep attachment wounds. Part of a healthy therapeutic experience is to allow attachment to form within a contained therapeutic space.

Therapists must understand the responsibility of being a “stand-in” attachment figure. As the client builds trust and allows themselves to attach, we must remain steady and reliable, with compassionate, clear boundaries. With attachment and healing side-by-side, eventually the therapist can support a client to begin building trust within their personal relationships.

Children who endure early sexual abuse, especially when it is perpetrated by a caregiver, often associate safety with sexual sensations. When a person begins to feel containment and compassion from a therapist, this can cause an automatic response of arousal because of these early experiences. Clinicians need to be able to have open, kind conversations with a person about these experiences. They must be able to hold clear, compassionate boundaries while continuing to engage in the therapeutic process.

Listening to explicit traumatic material

Vicarious traumatization can happen. Survivors of complex trauma may need to describe periods of extreme abuse. This can be a way to include the therapist in carrying the burden. However, therapists with unresolved trauma, or who have worked with a client with C-PTSD, may become vicariously traumatized. This not only harms the therapist, but will ultimately cause a rupture in the therapeutic relationship.

Therapists need to be able to hold a sacred, steady space while allowing clients to express any events they need to.

Containment and pacing

When working with clients with complex trauma, safety is everything. Our space needs to be consistent, our demeanor needs to be consistent, and our sessions need to be consistent as much as possible. Pacing is knowing how quickly to encourage clients to access trauma.

We must be very careful. Diving into the deep end of serious trauma too soon can cause an over-attachment to the therapist, inability to contain between sessions, decompensation, or suicidal ideation. Working with complex trauma can be a very slow process. Therapists need to understand how to pace an individual’s journey, notice when it’s going too fast, and also when they seem ready to move forward.

Exposure

Exposure is part of working through complex trauma. Too often, therapists want to solve a client’s suffering rather than allowing the wounds to be felt. A client needs to feel through the horrific pain they’ve suffered within the safe, slowly paced container of the therapeutic space. Intense emotion is not to be avoided. However, therapists need to be trained in treating dissociation.

When flooding becomes intolerable, a protector will step in, such as dissociation. Therapists need to know how to recognize this and how to work with it effectively. Holding specific skills and methodologies There are specific methods that work for complex trauma. These include somatic-based therapies, internal family systems, trauma-informed yoga, creative therapies, and/or animal-assisted therapies.

An important note about EMDR.

As most therapists know, EMDR is touted to be top of the line to treat PTSD. However, it has been shown to be less effect C-PTSD. EMDR can be effective at times, but must be used with great caution and after the client has reached secure stability. The level of exposure it asks of a client within the realm of the EMDR protocol can cause extreme flooding and inability to compartmentalize between sessions, which is likely too set back treatment.

Grief, death, and dying

Often clients experience abuse that caused fear of death, witnessed harm or death of another, have intense fear of being harmed or murdered, and deal with intense grief. Therapists must know how to allow clients to feel out these intense experiences. Therefore, they need training in grief therapy and also in how to work effectively with death and dying.

Often therapists feel uncomfortable addressing death and dying head-on. They may be concerned about upsetting the client, or they may have personal fears that hinder their ability to bring this into therapy. Therapists need to be able to address these heavy existential areas with courage.

Passive suicidality

Clients with complex trauma frequently have chronic passive suicidality. Therapists need to know how to hold and address this head-on. In other words, we need to be able to discuss suicide openly and how to assess passive suicidality with active risk of suicide. We need to know when we can contract for safety, how to involve others, and when to seek hospitalization.

Understanding Existentialism

Existential questioning is part of complex trauma. Clients have many questions such as, “why did this happen to me,” “what if there was meaning, what if it just happened,” “did I do something to deserve this? Was this karma,” and on and on.

Therapists need to know how to hold these questions with clients without trying to resolve them. We must be able to sit with the unknown and also know how to guide clients, very slowly, towards meaning-making.

Significant self-awareness

This is imperative. All therapists who work with complex trauma must be actively working on their personal self-awareness and healing journeys. Clients who have attachment wounds, horrific stories, emotional dysregulation, slow progress, and powerful dissociation are, at times, hard to sit with.

We can become activated; however, we must have the appropriate skills to regulate in sessions and resolve them between sessions. Unfortunately, there are many therapists working with clients who have complex trauma and either do not know how to provide appropriate care or do not know they have C-PTSD.

Misdiagnosis is common and tragic.

However, this is an entry in and of itself, which I will address in the future. Those therapists who are interested in working with C-PTSD, please ensure they have supervision and are seeking appropriate training.

A note from Sarah

Personally, I have experienced both misdiagnosis and inappropriate treatment from inexperienced clinicians. As a survivor of complex trauma, I was diagnosed with anxiety, bipolar II, depression, ADHD, and more. These were all only symptoms of the level of trauma I was holding in my body.

Once I understood that it was all under the umbrella of C-PTSD, I had more compassion for my struggles, yet anger at the larger system that missed my underlying reality. It is vital for us to be prepared to work with clients who present with with multiple diagnoses, a history of medication-resistance, or dissociation.

If therapists go into the difficult work without the correct skills, they can cause more harm than good.

Sarah offers individual clinical supervision, consultation services, and in-service training with attached CEU's

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I am so glad to have taken the time to read this entry; I appreciate you. Take good care of yourself and my brothers and sisters who are seeking your crucial support.

All Good Things.