Description
More than two decades ago, van der Hart, Brown, and van derKolk (1989), followed by Herman (1992b), described a three-stage psychotherapy for clients suffering from complex traumatic stress disorders that elaborated a model formulated a century earlier by the French psychiatrist Pierre Janet (1889/1973). Since its reintroduction, Janet’s sequenced treatment model, designed to stabilize the client before reworking and resolving the trauma and its effects, has been applied fairly extensively to the treatment of complex developmental trauma and related dissociative disorders. A clinical consensus and evidence base for this approach and associated techniques are currently under development (Cloitre et al., 2011; Courtois & Ford, 2009). In this book, we build on the foundation of this earlier work and incorporate newly available scientific data and technical innovations in clinical practice to further advance a phase-based treatment model. In addition, we address challenges and nuances in the treatment of complex trauma that require creative and sensitive application of clinical concepts and techniques that must be tailored to the needs of the individual client.
Although the sequenced (or phased) model described here is linear on paper, it is dynamic in practice and not applied in a lockstep fashion; rather, tasks and techniques of each phase are organized on the basis of a number of factors, primarily the client’s clinical status, emotion-regulation capacity, motivation, and response to treatment. Client resilience and strengths are assessed and built upon right from the start; however, many clients can be expected to have difficulties learning and applying new skills. Accordingly, relapse planning is built into the model, and setbacks are not considered failures but rather indications of the need to revisit therapeutic tasks and to relearn or burnish recently attained skills. From this perspective, the sequenced model can be conceptualized as an upward spiral of therapeutic tasks that are completed progressively. It is simultaneously a recursive model in which clients routinely return to earlier learning tasks and in which various skills are learned and challenged and then revisited reworked, and solidified in an ever-progressive way through all three treatment phases. The upward spiral is hierarchical, built on a foundation of improved and newly attained skills in emotion regulation and on greater life stability, and the secure base of the therapy relationship. These, in turn, can lead to enhanced self-esteem, better relationships, and overall life improvement. Initially, progress often is of the “two steps forward, one step back” variety; subsequently, it becomes more steps forward and fewer steps back as the client gains mastery and achieves therapeutic goals.
The book begins with two chapters that describe complex forms of psychological trauma and associated complex traumatic stress symptoms and disorders. We highlight the importance of utilizing a comprehensive diagnosis such as complex posttraumatic stress disorder/disorders of extreme stress not otherwise specified (DESNOS; Herman, 1992a) or developmental trauma disorder (DTD; van der Kolk, 2005) in order to fully address the range of “complex traumatic stress disorders” (Courtois & Ford, 2009). We next devote two chapters to the practical preparations necessary to work with complex posttraumatic conditions, including practice tools and policies to reasonably manage risk, the establishment of a strong therapeutic alliance, crisis prevention and management, and initial assessment. In Chapter 5 we introduce the three phase model of treatment, and discuss Phase 1 emphases—safety, client engagement and education, and skill building. Chapter 6 continues with an in-depth discussion of the nuances of Phase 2—trauma processing with clients who have complex traumatic stress disorder— and concludes with a description of Phase 3 interventions that assist the client in applying therapy gains to daily life. Chapter 7 introduces the use of three systemic treatment modalities: group, couple, and family therapy. Chapter 8 addresses advanced issues related to treating severe affect dysregulation and dissociation and their many associated identity, somatic, behavioral, and relational manifestations. Chapter 9 challenges therapists to attend scrupulously to their own emotion regulation and to the management of professional boundaries and limitations, in order to be therapeutically available but “not too close and not too distant.” The book concludes by addressing some of the complex transference and countertransference dilemmas encountered by therapists treating clients with complex trauma histories.
For readers interested in deepening their exploration of complex PTSD and its treatment, we have created self-reflection questions to accompany each chapter, as well as lists of additional resources for professionals, clients, and students. These are available in downloadable form from Guilford’s website at www.guilford.com/p/courtois.