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Complex Trauma requires a Stage by Stage Evidence Based Approach
Complex Trauma requires a Stage by Stage Evidence Based Approach
Complex trauma is fundamentally different in terms of treatment to "single event" trauma, also known as PTSD. Post Traumatic Stress Disorder results when a single event is so overwhelming that the outcome is trauma. This is usually identified through the symptoms associated with trauma in the diagnostic criteria of the ICD or DSM.
Complex Trauma, or Complex-PTSD is not fully explained as different in either diagnostic system, but essentially although it shares many of the symptom outcomes, results not from single event, or events, but from the cumulative effect of trauma over time. This has certain major differences in practice. Perhaps the most important difference is that the main problem with C-PTSD is the adaptation that occurs as a result of prolonged exposure. Adaptation is the process of adapting perception, behaviour, social behaviour and habits in order to survive. It is thus not a fault or illness, it is a necessary survival mechanism. After the trauma ends however these changes become ingrained and hard to shift without support and patience, and this is often called re-adaptation. This is different to single event PTSD where the main damage is caused by memory fragmentation at the single event. Some memory fragmentation often occurs with complex trauma, however resolving this is not the main concern in enabling recovery from complex trauma. Indeed in most cases little or no memory recovery and processing is needed in complex trauma, and any that is needed is fairly late in the process and designed to "tidy up" residual flashbacks or issues after the main recovery is complete.
Because the process is different it is crucial that PTSD focused therapists do not treat C-PTSD in the way they would treat s single event trauma. in complex trauma case if you start memory reprocessing part of the trauma memory without doing the necessary work first, it is probably unnecessary clinically anyway, but it will almost certainly cause harm because for the complex trauma survivor's brain it will be impossible to tell that this is "therapy" and not another occurrence of trauma. This is because in complex trauma the survivor is accustomed to the trauma being repeated, and therefore some well meaning therapist trying to access memory of trauma is impossible to tell apart from yet another repetition.
So to summarize - if you rush to process memory in complex trauma, the client's brain will think it is happening again, and harm will result! this applies to hypnosis, EMDR, NLP, trauma debriefing, indeed any memory reprocessing method.
Before addressing any parts of memory that need to be resolved, the other main goals of complex trauma therapy must be completed. The easiest way to determine whether the client is ready is twofold:
Has the client completed stage one and most of stage two, so they are self regulated, able to calm themselves, and understand neurology and the patterns of their traumatic experiences
Can the client discuss traumatic results, even the deeper somatic feelings, while remaining in a relaxed, calm, non triggered body
Stages of complex Trauma Treatment - general summary
Stages of complex Trauma Treatment - general summary
Phase 1: Safety and Stabilization
Focus: Establishing a sense of safety, both physically and emotionally. This involves creating a stable environment, developing coping skills, and learning self-regulation techniques to manage intense emotions and physical reactions.
Key components:
Building a therapeutic relationship based on trust and safety.
Psychoeducation about trauma and its effects.
Developing self-soothing and grounding techniques.
Addressing any immediate safety concerns (e.g., domestic violence, substance abuse).
In vivo exposure - using real current in life small challenges to experience increasing resiliance, confidence and ability to self regulate. Clients often have to be reminded that when clearing the clutter and current hassles from their lives they are not wasting time or delaying recovery, they are gaining vital resiliance, confidence and insight.
Phase 2: Processing Traumatic Memories
Stage two initial:
Mapping how the gained meaning of the traumatic periods has influenced you mentally, behaviour, physically, socially etc
Understanding your individual adaptations and how they effect your perception, behaviour and outcomes
Choosing new outcomes and re-adaptations. using neurology informed behavioural analysis and change to make lasting difference
Combining the above into a new narrative: often called narrative based therapy
Using narrative processes to challenge normalised experiences (things that happened that seemed normal until you actually reflect on them later)
Interpersonal Relationships and attachments
Challenging "trauma think" - deeply held core beliefs about life that are adapted because of trauma
Stage two advanced:
Where needed addressing the traumatic memories themselves, although this is thematic and there is absolutely no need to remember everything in detail!. This involves processing the emotions, sensations, and beliefs associated with the trauma in a safe and controlled way. This usually involves somatic processing to access the implicit memory, which contains the hidden memory. One way to imagine this is the idea of the phrase "because I experienced "xxxxx", I tend to feel "yyyy". And from that using behavioural change to move towards new chosen perceptions and behaviours.
Key components:
Utilizing trauma-focused therapies such as EMDR, Cognitive Processing Therapy, or Somatic Experiencing to determine emotional themes and patterns, and where needed to re-assemble fragmented memory.
Gradually understanding and processing traumatic meaning, in complex trauma focusing on meaning and outcomes rather than details.
Working through difficult emotions such as shame, guilt, and anger.
Phase 3: Integration and Re-connection
Focus: Life beyond trauma. This involves developing a sense of self beyond the trauma, building healthy relationships, and pursuing meaningful goals. This can be more complex than people expect since until this point so much energy and head space has been dedicated to survival.
Key components:
Developing a new sense of self and identity.
Working on interpersonal relationships and social skills.
Finding meaning and purpose in life.
Building resilience and coping skills for future challenges.
It's important to note that these phases are never linear, and individuals move back and forth between them as needed. The treatment process is highly individualized and should be tailored to the specific needs and experiences of each person.
Additional Considerations:
Therapeutic Relationship: A strong and supportive therapeutic relationship is essential throughout the entire treatment process.
Individualized Approach: Treatment should be tailored to the specific needs and experiences of each individual.
Pace: The pace of treatment should be determined by the individual, and it's important to avoid pushing too hard or too fast.
Self-Care: Engaging in self-care activities such as exercise, relaxation, and creative expression can be helpful throughout the treatment process.
Original gold standard, the Judith Herman model
Original gold standard, the Judith Herman model
For reference, the original gold standard model of evidence based staged complex trauma treatment was developed by Herman and is also known as the NARM model since Heller, the founder of NARM Institute promotes it as part of their training. All subsequent adapted and enhanced models are based on this excellent tried and tested method. That includes the 4 stage version of the NARM model used by Trauma institute International, Stuart's main affiliation and accreditation body.
The NeuroAffective Relational Model (NARM) is a cutting-edge approach to healing complex trauma, also known as developmental trauma. Developed by Dr. Lawrence Heller, NARM focuses on the impact of early childhood experiences on our present-day lives, emphasizing our strengths and resilience rather than pathology.
Here's a breakdown of key aspects of the NARM model:
Core Principles:
Relational and Developmental: NARM recognizes that our earliest relationships shape our sense of self, our ability to regulate emotions, and how we connect with others. It explores how early attachment patterns and unmet needs can lead to lasting challenges.
Somatic Awareness: NARM integrates awareness of the body's sensations and responses into the therapeutic process. It acknowledges that trauma is not just a psychological experience but also deeply affects our physiology.
Shame and Self-Regulation: NARM addresses the pervasive role of shame in developmental trauma. It helps individuals develop self-regulation skills to manage intense emotions and cultivate a stronger sense of self-worth.
Identity and Attachment: NARM explores how early experiences influence our sense of identity and our patterns of attachment. It supports individuals in reclaiming their authenticity and agency.
Key Features:
Focus on Strengths: NARM emphasizes individuals' inherent capacities for healing and growth. It highlights resilience and resources rather than solely focusing on deficits or problems.
Present-Moment Focus: While acknowledging the impact of the past, NARM primarily works in the present moment. It helps individuals become aware of how past experiences are influencing their current thoughts, feelings, and behaviors.
Mind-Body Integration: NARM utilizes a combination of "top-down" (cognitive and emotional processing) and "bottom-up" (somatic experiencing) approaches to address trauma on multiple levels.
Non-Pathologizing Approach: NARM avoids labeling or diagnosing individuals. It views symptoms as adaptive responses to challenging circumstances, recognizing the person's innate wisdom and resourcefulness.
How NARM Works:
NARM therapy involves a collaborative exploration between the therapist and client. The therapist creates a safe and supportive environment for the client to:
Develop awareness: Become more attuned to their internal experiences, including bodily sensations, emotions, and thoughts.
Explore patterns: Identify recurring patterns in their relationships and behaviors that may stem from early experiences.
Heal shame: Address and resolve feelings of shame and self-blame.
Build self-regulation: Develop skills to manage emotions and cope with stress.
Reclaim identity: Discover and embrace their authentic self, separate from the impact of past trauma.
Benefits of NARM:
Addresses root causes: NARM goes beyond symptom management to address the underlying causes of complex trauma.
Promotes healing: It supports deep and lasting healing by integrating mind, body, and emotions.
Empowers individuals: NARM helps individuals reclaim their sense of agency and create more fulfilling lives.
Enhances relationships: It improves the capacity for healthy and satisfying relationships.
While NARM doesn't have strictly defined "stages" like some other trauma treatment models, it does progress through a process of deepening awareness and integration. Here's how that generally unfolds:
1. Establishing Safety and Connection:
Building the Therapeutic Relationship: This is paramount in NARM. The therapist creates a safe, non-judgmental space where the client feels seen, heard, and understood. This fosters trust, which is crucial for exploring vulnerable material.
Somatic Awareness: The client begins to gently tune into their body sensations. This is a foundation for understanding how past experiences are held in the body and how they influence present-day reactions.
Psychoeducation: The therapist may provide education about complex trauma, its impact, and the NARM approach. This helps the client understand their experiences within a framework of healing and resilience.
2. Exploring Patterns and Survival Styles:
Identifying Core Themes: Together, therapist and client explore the client's history, focusing not just on events but on the underlying emotional themes and unmet needs that shaped their development.
Understanding Survival Styles: NARM identifies five core "survival styles" that develop in response to early adversity. The client and therapist work to understand which styles are prominent in the client's life and how they manifest in thoughts, feelings, and behaviors.
Present-Moment Focus: The emphasis is on how these past patterns are playing out in the client's current life and relationships. The client learns to recognize the triggers and internal processes that lead to dysregulation and disconnection.
3. Addressing Shame and Reclaiming Identity:
Working with Shame: Shame is a central focus in NARM. The therapist helps the client identify and gently explore the sources of shame, challenging self-blame and fostering self-compassion.
Reclaiming Agency: As shame diminishes, the client begins to reclaim a sense of agency and choice. They start to see that their survival strategies, while once necessary, may no longer be serving them.
Embracing Authenticity: The client is supported in connecting with their authentic self, separate from the adaptations they made to survive early challenges. This involves exploring their values, needs, and desires.
4. Integration and Moving Forward:
Building Resilience: The client develops greater self-regulation skills and a deeper understanding of their internal world. This builds resilience to navigate future challenges.
Enhancing Relationships: As the client heals, their capacity for healthy, fulfilling relationships often improves. They may develop new relationship patterns based on authenticity and mutual respect.
Living with Greater Presence: The client learns to live more fully in the present moment, less burdened by the past. They can access their emotions and needs with greater awareness and self-compassion.
Evidence - links to evidence, research and Internationally recognised standards
Evidence - links to evidence, research and Internationally recognised standards
Stage models, such as the Judith Herman 3 stage trauma model, particularly as expressed in the NeuroAffective Relational Model (NARM), focuses on developmental trauma and its impact on adult functioning. Here's a look at the scientific underpinnings of NARN and similar integrative models: NARM Here. and HERE Trauma Institute International Salutogenic Model HERE. United Kingdom NICE guidelines for clinical standards on PTSD HERE. World Health Organisation ICD definitions of trauma HERE. Internationally recognised descriptors of trauma from Blue Knot Charity HERE. Developmental Stress Disorder definitions HERE
Key Aspects and Supporting Concepts:
Developmental Trauma:
NARM emphasizes the impact of early childhood trauma on the development of the nervous system and the formation of survival patterns. This aligns with a growing body of research on Adverse Childhood Experiences (ACEs) and their long-term effects on physical and mental health. CDC evidence presented HERE
Studies on ACEs demonstrate a strong correlation between early trauma and increased risk for various health problems, including PTSD, depression, and chronic illness. This provides a scientific basis for NARM's focus on developmental trauma.
Neuroscience and the Body:
NARM incorporates principles of neuroscience, recognizing that trauma is stored in the body and affects the nervous system. This aligns with research on the neurobiology of trauma, which shows that traumatic experiences can alter brain structure and function.
The emphasis on somatic awareness and regulation in NARM is supported by research on the mind-body connection and the role of the autonomic nervous system in trauma responses. NARM research discussed HERE
Attachment Theory:
NARM draws on attachment theory, which emphasizes the importance of secure attachment in early childhood for healthy development.
Research on attachment theory has shown that insecure attachment patterns can result from early trauma and contribute to difficulties in relationships and emotional regulation. NARM addresses these attachment-related issues in its therapeutic approach.
Somatic Experiencing:
NARM integrates concepts from Somatic Experiencing (SE). SE has growing research that shows the benefits of focusing on bodily sensations in trauma therapy.
This focus on the body allows for the processing of trauma that is held in the implicit memory system, which is often inaccessible through traditional talk therapy.
Where More Research Is Needed:
While the underlying principles of NARM are supported by scientific research, more specific studies are needed to evaluate the effectiveness of NARM as a distinct therapeutic modality.
Further research could explore the neural mechanisms involved in NARM and its impact on specific trauma-related symptoms.
In summary:
The Heller trauma model, particularly NARM, is grounded in established scientific concepts related to developmental trauma, neuroscience, and attachment theory.
The model's emphasis on the mind-body connection and somatic awareness is consistent with current research on the neurobiology of trauma.
While much of the foundation is supported by science, more specific research on NARM itself would be beneficial.
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