EPSY 401 Indiana State University Children and Trauma Essay

User Generated

ncryanefu

Writing

EPSY 401

Indiana State University

EPSY

Description

The midtermtraumapaper will focus on a topic related to children and trauma that you are interested in learning more about. It might be a particular traumatic experience or condition, a concept, an intervention, or a systems issue or policy. Pay careful attention to issues of diversity, including, but not limited to race, ethnicity, sexual orientation, gender bias, differently-abled, etc. The paper should be approximately 5 pages, exclusive of references. Use the course materials and readings as well as articles from peer-reviewed journals and books on your topic of interest. This paper should be written using APA format, including appropriate citations and a list of references. For assistance, refer to the APA guide provided at http://owl.english.purdue.edu/owl/resource/560/01/... examples of broad topics that can be further refined: War trauma; self-injury and its causes and treatment; substance abuse and its relationship to trauma; neurobiology of trauma; genocide and/or ethnic conflict; intergenerational transmission of trauma and/or resilience; domestic violence; institutional trauma; vicarious traumatization in social workers and other helpers. There are many other topics that can be explored—if you have questions, please do not hesitate to ask!

Unformatted Attachment Preview

T H E L E C T U R E S E R I E S Inaugural Lecture by Bruce D. Perry, M.D., Ph.D. Maltreatment and the Developing Child: How Early Childhood Experience Shapes Child and Culture Dr. Perry is an internationally recognized authority on child trauma and the effects of child maltreatment. His work is instrumental in understanding the impact of traumatic experiences and neglect on the neurobiology of the developing brain. He presented the inaugural Margaret McCain lecture on September 23, 2004 We seek to make the world a better place. No matter our profession or vocation, we share the desire – and the ability – to make a difference in a child’s life. Humans are complex creatures. While having the capacity to be humane, we also have the capacity to be cruel. Why? What determines whether a child grows up to be compassionate, thoughtful, and productive? Or, impulsive, aggressive, hateful, and non-productive? Is it genetic? Likely not. Human beings become a reflection of the world in which they develop. If that world is safe, predictable, and characterized by relationally and cognitively enriched opportunities, the child can grow to be self-regulating, thoughtful, and a productive member of family, community, and society. In contrast, if the developing child’s world is chaotic, threatening, and devoid of kind words and supportive relationships, a child may become impulsive, aggressive, inattentive, and have difficulties with relationships. That child may require special educational services, mental health or even criminal justice intervention. The challenge for us is to help each child reach his or her potential to be humane. To better understand how, we must appreciate the remarkable malleability of our species and the unique role played by the human brain. The Developing Brain The human brain mediates our movements, our senses, our thinking, feeling and behaving. The amazing, complex neural systems in our brain, which determine who we become, are shaped early. The brainstem controls heart rate, body temperature, and other survival-related functions. It also stores anxiety or arousal states associated with a traumatic event. Moving outward towards the neocortex, complexity of functions increases. The limbic system stores emotional information and the neocortex controls abstract thought and cognitive memory. Sharing ideas to help children thrive In utero and during the first four years of life, a child’s rapidly developing brain organizes to reflect the child’s environment. This is because neurons, neural systems, and the brain change in a “use-dependent” way. Physical connections between neurons – synaptic connections – increase and strengthen through repetition, or wither through disuse. It follows, therefore, that each brain adapts uniquely to the unique set of stimuli and experiences of each child’s world. Early life experiences, therefore, determine how genetic potential is expressed, or not. As the brain organizes, the lower more regulatory systems develop first. During the first years of life, the higher parts of the brain become organized and more functionally capable. Brain growth and development is profoundly “front loaded” such that by age four, a child’s brain is 90% adult size! This time of great opportunity is a biological gift. In a nurturing environment, a child can grow to achieve the full potential pre-ordained by underlying genetics. We can promote this by fostering conditions of optimal development. www.lfcc.on.ca T H E L E C T U R E S E R I E S Optimal Development A child is most likely to reach her full potential if she experiences consistent, predictable, enriched, and stimulating interactions in a context of attentive and nurturing relationships. Aided by many relational interactions – perhaps with mother, father, sibling, grandparent, neighbour and more – young children learn to walk, talk, self-regulate, share, and solve problems. Every child will face new and challenging situations. These stressinducing experiences per se need not be problematic. Moderate, predictable stress, triggering moderate activation of the stress response, helps create a capable and strong stress-response capacity, in other words, resilience. The first day of kindergarten, for example, is stressful for children. Those embedded in a safe and stable home base overcome the stress of this new situation, able to embrace the challenges of learning. Disrupted Development While most children experience safe and stable upbringings, we know all too well that many children do not. The very biological gifts that make early childhood a time of great opportunity also make children very vulnerable to negative experiences: inappropriate or abusive caregiving, a lack of nurturing, chaotic and cognitively or relationally impoverished environments, unpredictable stress, persisting fear, and persisting physical threat. These adverse effects could be associated with stressed, inexperienced, ill-informed, pre-occupied or isolated caregivers, parental substance abuse and/or alcoholism, social isolation, or family violence. Chronic exposure is more problematic than episodic exposure. In the most extreme and tragic cases of profound neglect, such as when children are raised by animals, the damage to the developing brain – and child – is severe, chronic, and resistant to interventions later in life. A hyperarousal response is more common in older children, males, and in circumstances where trauma involves witnessing or playing an active role in the event. The dissociative response involves avoidance or psychological flight, withdrawing from the outside world and focusing on the inner. The intensity of dissociation varies with the intensity These images illustrate the negative impact of of the trauma. Children may be neglect on the developing brain. The CT scan detached, numb, and have a low heart on the left is from a healthy three-year-old rate. In extreme cases, they may with an average head size. The image on the right is from a three-year-33old child suffering withdraw into a fantasy world. A dissociative child is often compliant from severe sensory-deprivation neglect. This child’s brain is significantly smaller and has (even robotic), displays rhythmic selfabnormal development of cortex. soothing such as rocking, or may faint if feeling extreme distress. Dissociation is The Adaptive more common in young children, females, and during traumatic events Response to Threat characterized by pain or inability to When a child is exposed to any threat, escape. his brain will activate a set of adaptive Differential “State” responses designed to help him survive. There is a continuum of adaptive Reactivity responses to threat and different A child with a brain adapted for an children have different adaptive styles. environment of chaos, unpredictability, Some use a hyperarousal response (e.g., threat, and distress is ill-suited to the fight or flight) and some a dissociative modern classroom or playground. It is response (essentially “tuning out” the an unfortunate reality that the very impending threat). In most traumatic adaptive responses that help the child events, a combination of the two is survive and cope in a chaotic and used. unpredictable environment puts the child at a disadvantage when outside that context. Traumatic Event When children experience repetitive activation of the stress response Prolonged systems, their baseline state of arousal is altered. The result is that even when Alarm Reaction there is no external threat or demand, they are physiologically in a state of alarm, of “fight or flight.” When a Altered Neural stressor arises, perhaps an argument Systems with a peer or a demanding school task, they can escalate to a state of fear very A child adopting a hyperarousal quickly. When faced with a typical response may display defiance, easily exchange with an adult, perhaps a misinterpreted as wilful opposition. teacher in a slightly frustrated mood, These children may be resistant or the child may over-read the non-verbal even aggressive. They are locked in cues such as eye contact or touch. a persistent “fight or flight” state. Compared to their peers, therefore, They often display hypervigilance, traumatized children may have less anxiety, panic, or increased heart rate. capacity to tolerate the normal demands and stresses of school, home, and social life. When faced with a challenge, for example, resilient children are likely to stay calm. Normal children in the same situation may become vigilant or perhaps slightly anxious. Vulnerable children will react with fear or terror. Fear Changes the Way We Think Children in a state of fear retrieve information from the world differently than children who feel calm. In a state of calm, we use the higher, more complex parts of our brain to process and act on information. In a state of fear, we use the lower, more primitive parts of our brain. As the perceived threat level goes up, the less thoughtful and the more reactive our responses become. Actions in this state may be governed by emotional and reactive thinking styles. As noted above, when children experience repetitive activation of the stress response systems, their baseline state of arousal is altered. The traumatized child lives in an aroused state, ill-prepared to learn from social, emotional, and other life experiences. She is living in the minute and may not fully appreciate the consequences of her actions. Add alcohol to the mix, or other drugs, and the effect is magnified. Decreasing the Alarm State It is important to understand that the brain altered in destructive ways by trauma and neglect can also be altered in reparative, healing ways. Exposing the child, over and over again, to developmentally appropriate experiences is the key. With adequate repetition, this therapeutic healing process will influence those parts of the brain altered by developmental trauma. Unfortunately most of our therapeutic efforts fall short of this. We can also be good role models: in all our interactions with children we can be attentive, respectful, honest, and caring. Children will learn that not all adults are inattentive, abusive, unpredictable, or violent. It is paramount that we provide environments which are relationally enriched, safe, predictable, and nurturing. Failing this, our conventional therapies are doomed to be ineffective. If a child is in a therapeutic relationship, we can help him better understand the feelings and behaviours that are the legacy of abuse and neglect. Information helps. A traumatized child may act impulsively and misunderstand why – perhaps believing she is stupid, bad, selfish or damaged. We can also teach adults in a child’s life about how traumatized children think, feel, and behave. Among the possible therapeutic options to help maltreated and traumatized children are cognitivebehavioural therapy, individual insightoriented psychotherapy, family therapy, group therapy, play or art therapy, eyemovement desensitization and reprogramming (EMDR), and pharmacotherapy. Each of these has some promising results and many disappointments. Therapy with maltreated children is difficult for many reasons. In the long term, the wisest strategy is to prevent abusive, neglectful, and chaotic caregiving. In that way, fewer children will require therapy. Prevention and Solutions We are the product of our childhoods. The health and creativity of a community is renewed each generation through its children. The family, community, or society that understands and values its children thrives; the society that does not is destined to fail. To truly help our children meet their potential, we must adapt and change our world. Some ways to do this follow: 1) Promote education about brain and child development We must as a society provide enriching cognitive, emotional, social, and physical experiences for children. The challenge is how best to do this. Understanding fundamental principles of healthy development will move us beyond good intentions to help shape sensitive caregiving in homes, early childhood settings, and schools. Research is key. Public education must be informed by good research and by the implementation and testing of educational and intervention programs. An important component of public understanding must be awareness of the power of the media over children. What to do? Integrate key principles of brain development, child development and caregiving into public education. We presently require more formal education and training to drive a car than to be a parent. More research in child development and basic neurobiology is needed to guide sensible changes in policy, programs and practice. 2) Respect the gifts of early childhood Enriching environments do exist. Many homes and high-quality, early childhood educational settings provide the safe, predictable, and nurturing experiences needed by young children. Unfortunately, we often squander the wonderful opportunity of early childhood. At a time when the brain is most easily shaped – infancy and early childhood – we spend the fewest public dollars to influence brain development. However, expenditures on programs designed to change the brain dramatically increase for later stages of development (e.g., mental health, substance abuse or juvenile justice interventions). Investing in high-quality early childhood programs could avoid the expensive, often inefficient or ineffective, interventions required later. Unfortunately, these expensive interventions can be reactive, fragmented, chaotic, disrespectful and, sadly, sometimes traumatic. Our public systems may recreate the mess that many abused and neglected children find in their families. What to do? Innovative and effective early intervention and enrichment models exist. Integrate them into the policy and practices in your community. Help the most isolated, at-risk young parents connect with community resources, both pre-natally and postpartum. Demand and support high standards for child care, foster care, education, and child protective service. Brainʼs Capacity to Change Age 0 3 l Spending on Programs to “Change the Brain” 6 l 12 l 20 ....Mental Health........Juvenile Justice.. ...Headstart.........Public Education..........Substance Abuse Tx... 3) Address the relational poverty in our modern world We are designed for a different world than we have created for ourselves. Humankind has spent 99 percent of its history living in small, intergenerational groups. A child’s day brought many opportunities to interact with the variety of caregivers available to protect, nurture, enrich, and educate. But, the relational landscape is changing. Today, with our smaller families, we have less connection with extended families and fewer opportunities to interact with neighbours. Children spend a great deal of time watching television. While we in the western world are materially wealthy, we are relationally impoverished. Far too many children grow up without the number and quality of relational opportunities needed to organize fully the neural networks to mediate important socioemotional characteristics such as empathy. What to do? Increase opportunities for children to interact with others, especially those who are good role models. Simple changes at home and school can help: limiting television use, having family meals, playing games together, including neighbours, extended family and the elderly in the lives of children, and bringing retired volunteers into schools to create multiage educational activities. teacher interactions. Specific ways to foster strengths at home and at school are suggested on The ChildTrauma Academy’s website: www.ChildTrauma.org 4) Foster healthy developmental strengths The effects of maltreating and traumatizing children have a complex impact on society. Because our species is always changing, better understanding of these issues would help us develop more effective solutions. The human brain is designed for life in small, relationally healthy groups. Law, policy and practice that are biologically respectful are more effective and enduring. Unfortunately, many trends in caregiving, education, child protection and mental health are disrespectful of our biological gifts and limitations, fostering poverty of relationships. If society ignores the laws of biology, there will inevitably be neurodevelopmental consequences. If, on the other hand, we choose to continue researching, educating and creating problem-solving models, we can shape optimal developmental experiences for our children. The result will be no less than a realization of our full potential as a humane society. Certain skills and attitudes help children meet the inevitable challenges of life. They may even inoculate children against the adverse effects of violence. A child who develops six core strengths will be resourceful, successful in social situations, resilient, and may recover quickly from stressors and traumatic incidents. When one or more core strengths does not develop normally, the child may be vulnerable (for example, to bullying and/or being a bully) and may cope less well with stressors. These strengths develop sequentially during the child’s life, so every year brings opportunities for their expansion and modification. What to do? The major providers of early childhood experiences are parents. Supporting and strengthening the family will increase the likelihood of optimal childhood experiences. Also important will be peer and Dr. Bruce Perry’s Conclusion Six Core Strengths for Children: A Vaccine Against Violence ATTACHMENT: being able to form and maintain healthy emotional bonds and relationships SELF-REGULATION: containing impulses, the ability to notice and control primary urges as well as feelings such as frustration AFFILIATION: being able to join and contribute to a group ATTUNEMENT: being aware of others, recognizing the needs, interests, strengths and values of others TOLERANCE: understanding and accepting differences in others RESPECT: finding value in differences, appreciating worth in yourself and others For more information on the Six Core Strengths, visit the “Meet Dr. Bruce Perry” page at http://teacher.scholastic.com/professional/bruceperry Margaret Norrie McCain The Honourable Margaret N. McCain was co-chair with Dr. Fraser Mustard of the highly regarded Early Years Study: Reversing the Real Brain Drain (1999) and is the Children's Champion at Voices for Children. Among her many accomplishments, she is a founding member of the Muriel McQueen Fergusson Foundation in New Brunswick whose mission is the elimination of family violence through public education and research. The Lecture Series I n September, we held the first of an annual series of lectures addressing topics of interest shared by Margaret and our Centre, such as the early years and the effects of violence on children. All proceeds go to the Centre's Upstream Endowment campaign. We are delighted that Margaret has agreed to lend her name to our new lecture series. We greatly admire her dedication to children’s interests. We are also pleased that Dr. Bruce Perry agreed to be the inaugural speaker. An audience of over 300 watched his lecture at the London Convention Centre. His approach is in harmony with our own in many ways: begin early, apply a developmental framework, understand how children cope with adversities, support caregivers to support children, and help professionals understand how children think, feel and learn. For those not able to join us for the inaugural lecture, we are providing here a summary of Dr. Perry’s talk. We hope you can join us at the next lecture. Linda Baker Ph.D., C.Psych., Executive Director Centre for Children & Families in the Justice System. I am delighted that Dr. Bruce Perry was invited to give the inaugural Margaret McCain Lecture because he is a person whose work I have long admired. His research and writing on the effects of family violence on children have had an enormous influence on me. In fact, they led to my decision to focus my time and energy on early child development. Dr. Perry should be listened to by all politicians and policy makers at the highest levels. The information he presents is powerful and irrefutable and it could change dramatically the lives of children and families. Margaret N. McCain Margaret is seen here between Dr. Peter Jaffe and Dr. Linda Baker ...a Note from the Series Editor Researchers repeatedly find statistical correlations between living with violence – at home and in the community – and problematic outcomes in children. The most sophisticated studies show us how the correlations are mediated and moderated by factors themselves correlated with violence, including economic poverty, child maltreatment, emotional and physical neglect, parental substance abuse, parental stress, and parental mental illness. These large studies prove what front-line workers already know: children living with adult domestic violence rarely experience violence as the only life adversity. At the Centre, we call this the “adversity package”, a term used by Dr. Robbie Rossman. Dr. Perry calls it the “malignant combination of experience”. Simply put, the more obstacles in front of a child, the harder time he or she has navigating the journey down the road of childhood, especially if progress is judged against peers racing forward unencumbered by adversities What causally links the “adversity package” and poor child outcome? What mechanism or mechanisms is at work to reduce a child’s chances for success in life? Finding those mechanisms is the key to designing effective prevention and intervention strategies. Some observers focus on learning and modelling, while others see psycho-dynamic factors as important. Feminist thought and gender analysis have had a great impact on our collective understanding of violence. Each view has different implications for intervention. Dr. Perry posits another causal mechanism, hidden from view deep inside the brain. Traumatic features of a violent world – noise, chaos, fear, isolation, deprivation, neglect – alter the developing brain of fetuses, babies, and toddlers. Their brains adapt appropriately to toxic environments, but these adaptations are at odds with requirements for school and social relationships. These children are primed to survive their world, leaving them ill-prepared to achieve their full potential in our world. This document is a brief summary of Dr. Perry’s stimulating lecture, pointing readers to other sources of information. Alison Cunningham, M.A.(Crim.), Director of Research & Planning, Centre for Children & Families in the Justice System Bruce Perry M.D., Ph.D., Senior Fellow, Child Trauma Academy, Houston, Texas Dr. Perry served as the Thomas S. Trammel Research Professor of Child Psychiatry at Baylor College of Medicine and Chief of Psychiatry at Texas Children’s Hospital in Houston, from 1992 to 2001. Dr. Perry consults on incidents involving traumatized children, including the Columbine High School shootings, the Oklahoma City Bombing, the Branch Davidian siege and the September 11 terrorist attacks. He has served as the Director of Provincial Programs in Children’s Mental Health for Alberta, and is the author of more than 250 scientific articles and chapters. He is an internationally recognized authority in the area of child maltreatment and the impact of trauma and neglect on the developing brain. Dr. Perry attended medical and graduate school at Northwestern University and completed a residency in general psychiatry at Yale University School of Medicine and a fellowship in Child an Adolescent Psychiatry at the University of Chicago. Readers interested in additional material by Dr. Perry can visit the Child Trauma Academy at: www.childtrauma.org or www.childtraumaacademy.com (with free on-line courses) Bruce D. Perry (2004). Maltreated Children: Experience, Brain Development, and the Next Generation. New York: W.W. Norton. Additional Resources Recommended by Dr. Perry Marian Diamond & Janet Hopson (1999). Magic Trees of the Mind: How to Nurture Your Child's Intelligence, Creativity and Healthy Emotions from Birth Through Adolescence. Plume Books. Robin Fancourt (2001). Brainy Babies: Build and Develop Your Baby’s Intelligence. Penguin. Alison Gopnik, Andrew N. Meltzoff & Patricia Kuhl (2000). The Scientist in the Crib: Minds, Brains and How Children Learn. Perennial. Ronald Kotulak (1997). Inside the Brain: Revolutionary Discoveries of How the Mind Works. Andrews McMeel Publishing. Web Sites Attachment Parenting International: www.attachmentparenting.org Society for Neuroscience: www.sfn.org National Association to Protect Children: www.protect.org California Attorney General’s Safe from the Start Initiative: Reducing Children’s Exposure to Violence: www.safefromthestart.org T H E L E C T U R E S E R I E S is an initiative of: The Centre for Children & Families in the Justice System 200 - 254 Pall Mall St. LONDON ON N6A 5P6 CANADA www.lfcc.on.ca Proceeds from The Margaret McCain Lecture Series go to the Upstream Endowment. The Centre is a non-profit organization dedicated to helping children and families involved with the justice system, as young offenders, victims of crime or abuse, the subjects of custody/access disputes, the subjects of child welfare proceedings, parties in civil litigation, or as residents of treatment or custody facilities. For more information, including directions on how to make donations, visit We help vulnerable children achieve their full potentials in life, through professional training, resource development, applied research, public education, community collaboration and by providing informed and sensitive clinical services. www.lfcc.on.ca/ upstream.html Revenue Canada Charitable Registration No. 12991 5153 RR0001 ©2005 CENTRE FOR CHILDREN AND FAMILIES IN THE JUSTICE SYSTEM Psychotherapy: Theory, Research, Practice, Training 2004, Vol. 41, No. 4, 412–425 Copyright 2004 by the Educational Publishing Foundation 0033-3204/04/$12.00 DOI 10.1037/0033-3204.41.4.412 COMPLEX TRAUMA, COMPLEX REACTIONS: ASSESSMENT AND TREATMENT CHRISTINE A. COURTOIS This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Washington, DC, and Psychiatric Institute of Washington Complex trauma occurs repeatedly and escalates over its duration. In families, it is exemplified by domestic violence and child abuse and in other situations by war, prisoner of war or refugee status, and human trafficking. Complex trauma also refers to situations such as acute/chronic illness that requires intensive medical intervention or a single traumatic event that is calamitous. Complex trauma generates complex reactions, in addition to those currently included in the DSM–IV (American Psychiatric Association, 1994) diagnosis of posttraumatic stress disorder (PTSD). This article examines the criteria contained in the diagnostic conceptualization of complex PTSD (CPTSD). It reviews newly available assessment tools and outlines a sequenced treatment based on accumulated clinical observation and emerging empirical substantiation. Complex trauma refers to a type of trauma that occurs repeatedly and cumulatively, usually over a period of time and within specific relationships and contexts. The term came into being over the past decade as researchers found that some forms of trauma were much more pervasive and comChristine A. Courtois, independent practice, Washington, DC, and The CENTER: Posttraumatic Disorders Program, Psychiatric Institute of Washington, Washington, DC. Correspondence regarding this article should be addressed to Christine A. Courtois, PhD, 3 Washington Circle, Suite 205, Washington, DC 20037. E-mail: cacourtoisphd@aol.com 412 plicated than others (Herman,1992a, 1992b). The prototype trauma for this change in understanding was child abuse. The expanded understanding now extends to all forms of domestic violence and attachment trauma occurring in the context of family and other intimate relationships. These forms of intimate/domestic abuse often occur over extended time periods during which the victim is entrapped and conditioned in a variety of ways. In the case of child abuse, the victim is psychologically and physically immature—his or her development is often seriously compromised by repetitive abuse and inadequate response at the hands of family members or others on whom he or she relies for safety and protection. The expanded understanding also extends to other types of catastrophic, deleterious, and entrapping traumatization occurring in childhood and/or adulthood, for example, ongoing armed conflict and combat, POW status, and the displacement of populations through ethnic cleansing, refugee status, and relocation and through human trafficking and prostitution. It might also result from situations of acute and chronic illness that require ongoing and intensive (and often painful) medical intervention or may even result from a single catastrophic trauma, for example, witnessing the sudden traumatic death of another individual or experiencing a brutal gang rape. Diagnostic Conceptualization of Complex Trauma The diagnosis of posttraumatic stress disorder (PTSD) was first included in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM–III; American Psychiatric Association, 1980), largely because of the need for diagnostic nomenclature by which to describe the adverse reactions experienced by combat troops returning from Vietnam. It was derived from the observations and conceptualizations of early re- This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Special Issue: Complex Trauma, Complex Reactions searchers of war trauma (World Wars I and II and the Korean conflict; Kardiner, 1941) and included the symptom triad of reexperiencing, numbing/avoidance, and hyperarousal (American Psychiatric Association, 1980) and a phasic alternation between reexperiencing and numbing described by Horowitz (1976). The diagnosis was welcomed by those researching and treating combat trauma and by other researchers who were beginning to investigate other types of trauma, such as rape, domestic battering, and child abuse and neglect (particularly child sexual abuse/ incest). At the time, these researchers had begun to identify a number of posttraumatic syndromes in the various populations under study: rape trauma syndrome (Burgess & Holmstrom, 1974), battered woman syndrome (Walker, 1979, 1984), child abuse/sexual abuse trauma (Briere, 1984, 1987; Finkelhor, 1985), and incest trauma (Courtois, 1979a, 1979b; Herman & Hirschman, 1977). These researchers began to routinely apply the newly available diagnosis of PTSD to the effects they observed in their research and clinical samples. Another noteworthy inclusion in the third edition of the DSM was diagnostic criteria for dissociative disorders (DDs). The contemporary study of dissociation began during this same time period. Researchers began to find that DDs in children and adults were often related to reported histories of severe child abuse and neglect. Researchers of child abuse and dissociation, respectively, began to realize the crossover between their populations and came to understand that both areas of research involved trauma and posttraumatic reactions. Five different DDs were identified in the DSM–III: fugue, dissociative amnesia, depersonalization disorder, multiple personality disorder, and dissociative disorder, not otherwise specified (American Psychiatric Association, 1980). Despite the obvious advances that were made at the time in understanding posttraumatic reactions, a number of researchers and clinicians argued that the diagnosis of PTSD was not a perfect fit for the reactions experienced by victims of child abuse and domestic trauma and other populations where traumatization occurred repeatedly and extensively (Briere, 1987, 1992; Courtois, 1988; Finklehor, 1984; Herman, 1992a, 1992b). They noted that the criteria for PTSD had been derived directly from the study of adult male combatants exposed to war trauma. As a result, the reactions of those involved in combat were likely significantly different from those of immature individuals whose exposure to traumatic stress was ongoing and related to family life. Many researchers conducted factor analyses of the findings of available studies of child abuse trauma (findings summarized in Herman, 1992a, 1992b) and determined that the effects of such trauma, although posttraumatic in nature, were significantly different from PTSD as defined in the DSM–III (American Psychiatric Association, 1980). Individuals exposed to trauma over a variety of time spans and developmental periods suffered from a variety of psychological problems not included in the diagnosis of PTSD, including depression, anxiety, self-hatred, dissociation, substance abuse, self-destructive and risktaking behaviors, revictimization, problems with interpersonal and intimate relationships (including parenting), medical and somatic concerns, and despair. Moreover, these problems were categorized as comorbid conditions rather than being recognized as essential elements of complicated posttraumatic adaptations. Clinicians were discovering that these complex conditions were extremely difficult to treat and varied according to the age and stage at which the trauma occurred, the relationship to the perpetrator of the trauma, the complexity of the trauma itself and the victim’s role and role grooming (if any), the duration and objective seriousness of the trauma, and the support received at the time, at the point of disclosure and discovery, and later. Researchers involved in this work proposed an alternative conceptualization, complex PTSD (CPTSD) or “disorders of extreme stress not otherwise specified” (DESNOS; Pelcovitz et al., 1997). The PTSD committee for DSM–IV authorized a multisite field trial to investigate (a) alternative versions of the PTSD stressor criterion, (b) the validity of the items across stressors, (c) the adequacy of the tripartite division of symptoms, and (d) potential changes in the minimum required PTSD symptoms. An additional goal of the field trial was to examine the feasibility of a constellation of trauma-related symptoms (CPTSD) not addressed by the PTSD diagnosis and the reliability of a structured interview to measure this new conceptualization (Roth, Pelcovitz, Van der Kolk, & Mandel, 1997). Findings of this field trial, which took place between 1991 and 1992, demonstrated that CPTSD is specific to trauma, is rarely found among nontrauma exposed survivors 413 This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Courtois (has a high construct validity), and is comorbid with the diagnosis of PTSD. Follow-up studies examining CPTSD among combat veterans (Ford, 1999; Newman, Orsillo, Herman, Niles, & Litz, 1995), child abuse victims (Ford & Kidd, 1998), and battered women (Pelcovitz & Kaplan, 1995), as well as a study examining responses to fluoxetine (Van der Kolk et al., 1994) found support for the clinical usefulness of the symptom constellation, usefulness further supported by the inclusion of a similar diagnosis in the ICD-10 diagnosis of enduring personality change after catastrophic experience (World Health Organization, 1994). Since these early studies, research on a variety of populations and in a variety of settings has found support for the hypothesis that early interpersonal trauma, especially childhood abuse, predicts a higher risk for developing CPTSD/DESNOS than accidents and disasters (Roth et al., 1997). In a follow-up study of a specialized inpatient population of traumatized individuals, Ford (1999) found that despite substantial overlap between PTSD and DESNOS, the two conditions were substantially different in terms of symptoms and functional impairment. In contrast with the DSM–IV field trial finding of a 92% comorbidity rate between DESNOS and PTSD, Ford found that DESNOS could occur in the absence of PTSD (Ford, 1999), leading him to suggest that PTSD and DESNOS are fundamentally distinct in that PTSD symptoms do not account for those included in DESNOS. More research is needed to see if this finding holds. The diagnostic conceptualization of CPTSD/ DESNOS as defined for the field trial consisted of seven different problem areas shown by research to be associated with early interpersonal trauma (Herman, 1992a, 1992b): 1. alterations in the regulation of affective impulses, including difficulty with modulation of anger and self-destructiveness. This category has come to include all methods used for emotional regulation and self-soothing, including addictions and self-harming behaviors that are, paradoxically, often life saving; 2. alterations in attention and consciousness leading to amnesias and dissociative episodes and depersonalization. This category includes emphasis on dissociative responses different than those found in the DSM cri- 414 teria for PTSD. Its inclusion in the CPTSD conceptualization incorporates the findings regarding dissociation that were mentioned earlier, namely, that dissociation tends to be related to prolonged and severe interpersonal abuse occurring during childhood and, secondarily, that children are more prone to dissociation than are adults; 3. alterations in self perception, such as a chronic sense of guilt and responsibility, and ongoing feelings of intense shame. Chronically abused individuals often incorporate the lessons of abuse into their sense of self and self-worth (Courtois, 1979a, 1979b; Pearlman, 2001); 4. alterations in perception of the perpetrator, including incorporation of his or her belief system. This criterion addresses the complex relationships and belief systems that ensue following repetitive and premeditated abuse at the hands of primary caretakers; 5. alterations in relationship to others, such as not being able to trust and not being able to feel intimate with others. Another “lesson of abuse” internalized by victim/survivors is that people are venal and self-serving, out to get what they can by whatever means including using/abusing others; 6. somatization and/or medical problems. These somatic reactions and medical conditions may relate directly to the type of abuse suffered and any physical damage that was caused or they may be more diffuse. They have been found to involve all major body systems; 7. alterations in systems of meaning. Chronically abused individuals often feel hopeless about finding anyone to understand them or their suffering. They despair of ever being able to recover from their psychic anguish. Support for a diagnosis of CPTSD/DESNOS, although not yet incorporated into the DSM–IV except as an associated feature of PTSD (American Psychiatric Association, 1994), is growing. A number of clinicians have observed over the years that these adult survivors of childhood abuse present with complex symptom pictures, including engaging in many high-risk situations (self-harm, suicidality, risk-taking, addictions, revictimizations) as well as evidencing impair- This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Special Issue: Complex Trauma, Complex Reactions ments in their ability to regulate their emotions, to avoid revictimization, and to stay connected in a therapeutic relationship. These characteristics most resemble the symptom picture: emotional lability, relational instability, impulsivity, and unstable self-structure associated with borderline personality disorder (BPD; American Psychiatric Association, 1994), a diagnosis that has come to be understood as a posttraumatic adaptation to severe childhood abuse and attachment trauma (Briere, 1984; Herman, Perry, & van der Kolk, 1989; Kroll, 1993; Van der Kolk, Perry, & Herman, 1991; Zanarini, 1997). Despite this understanding, the BPD diagnosis has carried enormous stigma in the treatment community where it continues to be applied predominantly to women patients in a pejorative way. Conceptualizing and understanding BPD as a posttraumatic adaptation can assist the clinician in being more empathic and more even-handed. Yet, the treatment of individuals diagnosed with CPTSD/DESNOS or BPD is fraught with complications (Chu, 1992; Linehan, 1993); exposing these patients too directly to their trauma history in the absence of their ability to maintain safety in their lives can lead to retraumatization (Chu, 1998; Courtois, 1999). In recent years, treatment for patients with the “classic” form of PTSD has increasingly emphasized the use of cognitive–behavioral interventions (CBT), including prolonged exposure (PE) and cognitive restructuring (CR), techniques for which empirical support has become available (Foa, Keane, & Friedman, 2000a). The findings in support of the effectiveness of these techniques in ameliorating the often refractory symptoms of PTSD are laudable. Unfortunately, the wholesale application of CBT techniques to patients with CPTSD/DESNOS (even those who clearly meet criteria for PTSD) may be problematic and resurfaces some of the problems described in the previous paragraph. In fact, it is not too strong to say that some patients may actually be harmed by the use of these techniques, especially if applied too early in the treatment process without attention to safety and the ability to regulate strong affect (Chu, 1998; Ford, 1999; Ford & Kidd, 1998). Assessment and Treatment of Complex Trauma What follows is a description of an assessment and treatment model for CPTSD/DESNOS that attends to these concerns and sets out a sequenced course of treatment. It has as its foundation the development of skills for selfmanagement and safety applying cognitive and CBT techniques over the course of treatment. This model now has approximately 20 years of development based largely upon clinical application, observation, and modification. The aim of this article is to provide an overview and update of the treatment model, “the meta model,” and to set out the evolving standard of practice in the treatment of this class of conditions (Chu, 1998; Courtois, 1999). Empirical substantiation of various elements of the treatment model has been undertaken just recently (Ford, Courtois, Steele, Van der Hart, & Nijenhuis, in press); ongoing development of assessment and treatment will certainly rely upon the findings of these and additional studies. Assessment Strategies and instruments for the assessment of traumatized individuals are relatively recent developments in clinical practice. A variety of specialized instruments are now available (Briere, 2004; Carlson, 1997; Courtois, 1995; Wilson & Keane, 2004) for both posttraumatic and dissociative conditions (Dell, Dalenberg, Frankel, & Chefetz, 2003). Yet, the assessment of standard forms of PTSD using instruments developed for DSM–IV criteria (American Psychiatric Association, 1994) may unfortunately not cover the complexity of the CPTSD/DESNOS patient, including such issues as developmental aspects of the trauma history, functional and self-regulatory impairment, personal resources and resilience, and patterns of revictimization. The recommended approach to the assessment of trauma is to embed it within the standard psychosocial assessment conducted at the beginning of treatment. From the point of intake, the clinician should include questions having to do with possible trauma in the individual’s past and/or current life and about posttraumatic and/or dissociative symptomatology. The rationale for this recommendation is that a large number of individuals seeking mental health treatment do so for the direct or indirect consequences of traumatization at some point in their history and that individuals who meet diagnostic criteria for PTSD and for DDs are high end users of mental health services and thus are very likely to be presenting for treatment. 415 This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Courtois The clinician should not assume, however, that asking about trauma or trauma and dissociative symptoms will automatically result in disclosure. Some individuals with positive histories of trauma are unwilling or unable to disclose early in the process. Disclosure may only occur as the individual comes to know and trust the therapist. Whether the therapist is asking questions about trauma in an initial assessment or later in the treatment process, several guiding principles are to be emphasized. The client must be approached with respect and with the understanding that asking about trauma can be difficult and painful, as can the disclosure of past or current trauma. The issue of empowerment is another important one. The therapist must convey an attitude of openness and must ask questions from a neutral position of inquiry. If and when a trauma history is disclosed, the therapist then must pay careful attention to the individual’s condition in-session and afterwards (in the form of delayed reactions), with titration or even cessation of the inquiry if any decompensation occurs. Inquiry about and discussion of trauma details can cause the spontaneous emergence of symptoms in some individuals. The therapist should be aware ahead of time and be prepared to respond in a preventive way. Being sensitive to this range of possible responses conveys several important messages to the potential client—that the emotional content associated with traumatization can be overwhelming and that the therapist recognizes this and gives the individual’s safety and welfare precedence over the story. Finally, specialized assessment might need to be repeated at different points in treatment since posttraumatic and dissociative symptoms might only emerge gradually, often when enough safety is established in the treatment relationship. For, although some of these symptoms are blatant and highly evident, others are very subtle and have as their goal the maintenance of secrecy in the interest of safety. Unfortunately, most clinicians are not trained to recognize these symptoms and so might miss them. Once the clinician does recognize them and/or seeks consultation or training thereafter, he or she is in a much better position to recognize them in the future. Instruments If the therapist utilizes standard psychological instruments in the initial assessment (e.g., Min- 416 nesota Multiphasic Personality Inventory [MMPI], Millon Multiaxial Clinical Inventory [MCMI]), he or she should be aware that, although these instruments may tap many symptom and function domains, they will likely not tap those associated with posttraumatic and dissociative symptomatology. For this reason, it is recommended that the therapist supplement standard instruments with newly developed screening instruments, symptom inventories, and clinical interviews designed to encompass these domains. The following instruments have been developed specifically to assess the symptoms of PTSD and dissociation and have been found to have adequate reliability and validity. A discussion of the use of many of these instruments, alone or in conjunction with more standard instruments used in psychology and psychiatry, and an approach to the evaluation of trauma can be found in works by Briere (2004), Carlson (1997), Wilson and Keane (2004), and Briere and Spinazzola (in press). Posttraumatic symptoms, PTSD, and CPTSD. The following instruments are recommended at this time: Clinician-Administered PTSD Scale (CAPS; Blake et al., 1996), Impact of Event Scale—Revised (IES–R; Weiss & Marmar, 1997), Detailed Assessment of Posttraumatic States (DAPS; Briere, 2001), and Posttraumatic Stress Diagnostic Scale (PDS; Foa, 1995). Perhaps the two most useful in the identification of CPTSD are the Trauma Symptom Inventory (TSI), an instrument developed to assess trauma symptoms proper but that assesses domains of the self and relations with others (Briere, 1995; Briere, Elliot, Harris, & Cotman, 1995), and the Structured Interview for Disorders of Extreme Stress (SIDES), developed for the DSM–IV field trial (Pelcovitz et al., 1997; van der Kolk, 1999; Zlotnick & Pearlstein, 1997). Additionally, the Inventory of Altered Self Capacities (IASC; Briere, 2000b) assesses difficulties in relatedness, identity, and affect regulation and is therefore very pertinent to this population, as do the Cognitive Distortion Scales (CDS; Briere, 2000a) and the Trauma and Attachment Belief Scale (Pearlman, 2003), measures of trauma-related beliefs and cognitive distortions. Dissociative symptoms and the DDs. Several instruments are available to measure various aspects and types of dissociation: Dissociative Experiences Scale (DES; Bernstein & Putnam, 1986; Carlson & Putnam, 1993), a screening This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Special Issue: Complex Trauma, Complex Reactions rather than a diagnostic instrument that can be used first and then supplemented by other more detailed instruments, such as (and especially) the Multiscale Dissociation Inventory (MDI; Briere, 2002a) and the Somatoform Dissociation Scale (SDQ-20; Nijenhuis, 2000). Because of the often elusive nature of dissociation, a structured interview is often useful. Three are currently available: the Structured Clinical Interview for DSM– IV Dissociation Disorders, SCID-D (Steinberg, 1994; the only available interview with psychometric properties), the Office Mental Status Examination for Complex Chronic Dissociative Symptoms and Multiple Personality Disorder (Loewenstein, 1991), and the Dissociative Disorders Interview Schedule (DDIS; Ross et al., 1989). Results of these assessment instruments and interviews can guide the treatment process, as will be discussed in the second half of this article. Comprehensive assessment of the sort described above gives the clinician some understanding of the individual’s symptom picture, defensive and self structure, capacity for emotional selfregulation, functional competence, and relational ability. The clinician should be careful to assess for the individual’s strengths and resources, as well, so as not to fall into the countertransference trap of perceiving the individual as a helpless victim. Whenever possible, the therapist wants to call upon and reinforce the individual’s capacities; this will serve as a means of empowering the individual and will encourage growth (rather than regression) and an identity based upon functionality rather than debilitation. The therapist must also encourage appropriate dependence and provide a source of secure attachment for the traumatized individual as a base upon which the therapeutic work is conducted (see Dalenberg, this issue; Liotti, this issue). Treatment At the present time, the evolving standard of care for the treatment of PTSD includes psychotherapy supplemented by psychopharmacology (where appropriate and used to relieve posttraumatic symptoms as well as associated symptoms of depression, anxiety, obsessive–compulsive disorder and, on occasion, psychosis, carefully applied according to the needs of the client; Foa, Davidson, & Frances, 1999; Foa et al., 2000a). It should be noted that medication has not yet been found useful in specifically targeting dissociation, although the amelioration of symptoms of depression and anxiety may lessen the need for dissociative defenses. As discussed above, the use of cognitive–behavioral approaches, particularly exposure therapy, has received the most research substantiation for the treatment of classic forms of PTSD (Foa, Keane, & Friedman, 2000b). The use of these approaches with the CPTSD patient is just beginning and preliminary findings show some effectiveness (Resick, Nishith, & Griffin, 2003), yet significant caution is required in adopting this approach without further research. Hybrid models of treatment that combine or sequence strategies in different ways for the CPTSD client are currently under development, for CPTSD alone and in conjunction with chronic mental illness and with substance abuse. Where they have been tested, they have shown promise (Cloitre, 2002; Cloitre, Koenen, Cohen, & Han, 2002; Korn & Leeds, 2002; Leeds & Shapiro, 2000; McDonagh-Coyle, Ford, & Demment, 2002; Smucker & Dancu, 1999; Smucker & Niederee, 1995). Since research efforts are just beginning, these finding should be considered preliminary. Findings from these various research efforts as well as from clinical observation have suggested that many treatment approaches and strategies from a variety of theoretical perspectives apply to the treatment of the CPTSD population. Treatment is therefore multimodal and transtheoretical, necessitated in large measure by the multiplicity of problems and issues presented by these clients and by the fact that, CPTSD, like PTSD, has biopsychosocial and spiritual components that require an array of linked biopsychosocial treatment approaches. Moreover, CPTSD clients suffer from developmental/attachment deficits and issues, a situation that requires treatment strategies that are focused on ameliorating these deficits in order to advance the rest of the treatment. The treatment of CPTSD is cued to the diagnostic criteria that the seven areas of impairment described earlier: (a) alterations in the capacity to regulate emotions, (b) alterations in consciousness and identity, (c) alterations in selfperception, (d) alterations in perception of the perpetrator, (e) somatization, (f ) alterations in perceptions of others, and (g) alterations in systems of meaning. The treatment approach that is most recommended at the present time is that of 417 This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Courtois a meta-model that encourages careful sequencing of therapeutic activities and tasks, with specific initial attention to the individual’s safety and ability to regulate his or her emotional state (Chu, 1998; Courtois, 1999; Ford et al., in press; Herman, 1992b; Kluft, 2002; Linehan, 1993). The treatment has a whole-person philosophy that does not overemphasize the traumatic antecedents of the individual’s difficulties above all else, yet does give them appropriate emphasis and importance. Gold (2000) has labeled this strategy “not trauma alone,” and Courtois and Jay (1998) have labeled it “trauma responsive therapy.” The treatment model is highly individualized depending on the client’s needs and capabilities and recognizes that different healing patterns and prognoses are likely. Kluft (1994) has labeled this as treatment trajectories and has helpfully devised a rating scale of prognostic factors that generally predict a client’s treatment course of low, medium, and high gains. At this time, treatment for CPTSD is recognized as needing to be longer rather than shorter term in duration, because of the self-identity, self-regulatory, and relational deficits that are part of the larger symptom picture. Treatment may be conducted on an ongoing basis or more episodically. Additionally, it has been recognized that it is not unusual to have the resolution of one issue or set of issues precede the emergence of others (Chu, 1998; Courtois, 1999). Sequencing and Stage-Oriented Treatment The consensus or meta-model that is most in use in the contemporary treatment of CPTSD involves stages of treatment that are organized to address specific issues and skills (Courtois, 1999). A model consisting of three stages is widely adopted, following the recommendation made in Herman’s influential and pioneering book on CPTSD, Trauma and Recovery (Herman, 1992b). A model similar to this one was originally conceptualized and implemented for the treatment of chronic trauma by the French neurologist, Pierre Janet, at the end of the last century (Janet, 1919/1925; Van der Hart, Brown, & Van der Kolk, 1989). The early stage of treatment is devoted to the development of the treatment alliance, affect regulation, education, safety, and skill-building. The middle stage, generally undertaken when the client has enough life stability and has learned adequate affect modulation and coping skills, is directed toward the pro- 418 cessing of traumatic material in enough detail and to a degree of completion and resolution to allow the individual to function with less posttraumatic impairment. The third stage is targeted toward life consolidation and restructuring, in other words, toward a life that is less affected by the original trauma and its consequences. These three stages are described below, with the most emphasis on the first stage. It should be noted that although this metamodel does not prescribe or mandate particular interventions for particular clients, it does serve as a general guideline for the therapist that emphasizes safety, security, and affect regulation as core foundations of treatment. It also emphasizes posttraumatic growth and development and the ability to function in the world and seeks to halt the ongoing decline that is so often a legacy of complex trauma. Posttraumatic growth, described by Tedeschi and Calhoun (1995), involves enough consolidation of the biopsychosocial deficits and dysregulations to allow (a) new learning—especially involving affect identification, expression, and modulation—and (b) skill development that leads, in turn, to higher levels of functioning in different life spheres. Although the model is linear, it is not lockstep. Because posttraumatic decline and developmental deficits are difficult to reverse and because the development of trust requires time and effort, treatment usually proceeds in starts and stops. The model is most usefully conceptualized as a recursive spiral to account for this back and forth nature of what Kepner (1995) described as healing tasks within each stage and the likelihood that clients will advance and relapse as they progress through the various tasks. The model is also modified according to the specific issues that emerge during the initial assessment and later and according to the client’s defenses and such internal and external resources as ego strength, an available and stable support network, financial and insurance resources, and so forth. Stage 1: Pretreatment issues, treatment frame, alliance-building, safety, affect regulation, stabilization, skill-building, education, self-care, and support. This is likely to be the longest stage of the treatment and the most important to its success; thus, it is given the most description. It includes pretreatment issues such as the development of motivation for treatment, informed consent regarding the rules of treatment along with client rights and responsibilities, and education This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Special Issue: Complex Trauma, Complex Reactions about what psychotherapy is about and how to participate most successfully. It also begins the development of the treatment relationship in a way that allows a collaborative alliance over time. Saakvitne and colleagues (Saakvitne, Gamble, Pearlman, & Lev, 2000) have developed the acronym RICH to highlight the relationship elements that are most important in working with traumatized individuals: respect, information, connection, and hope. The underlying assumption of this treatment model, “Risking Connection,” is that the therapeutic relationship provides an opportunity to rework attachment difficulties from the past within the therapeutic context in order to develop greater self-capacities and specific personal and interpersonal skills. Stage 1 resembles more generic psychotherapy in many ways but, as noted by Courtois (1999), the patient’s posttraumatic aftereffects, including deficits in functioning, victimization-related schema about self and other, and episodes of revictimization, often compound it. For example, the development of the therapeutic alliance, a more or less straightforward process with a nontraumatized patient, is often a daunting challenge with one who has been severely interpersonally victimized. The patient may be beset by shame and anxiety and terrified of being judged and “seen” by the therapist. The therapist, in turn, may be perceived as a stand-in for other untrustworthy and abusive authority figures to be feared, mistrusted, challenged, tested, distanced from, raged against, sexualized, etc., or may be perceived as a standin for the longed-for good parent or rescuer to be clung to, deferred to, and nurtured by, or the two may alternate in unpredictable kaleidoscopic shifts (especially when the patient is highly dissociative and is easily triggered). In a related vein, issues of personal safety and revictimization are typically much more pronounced in this treatment population versus one that is more general. (p. 190) Some clients never move beyond or complete Stage 1. Others may leave treatment prematurely. It is now recognized that good work in Stage 1 is likely to substantially improve the client’s life. Some clients may have no need to move into the latter two stages. The primary emphasis of Stage 1 is personal safety in addition to education, personal and life stabilization, skill-building, and the building of social relationships and support. Safety is defined broadly and involves real and perceived injury and threats to self and to and from others. Many adult trauma survivors live in unsafe situations and relationships in which they are chronically revictimized and/or create risk and danger to themselves in ongoing conscious or unconscious reenactments of their original trauma. Some have no conceptualization of what it means to be safe and do not believe they can ever be safe. From its inception, treatment must be geared to the modification of such erroneous but trauma-related cognitions. The therapist assists the client to gain control over impulsive behavior, self-destructive thoughts and behaviors, dangerous interpersonal situations, addictions, ongoing dissociation, and intense affect discharges that can result in retraumatization and seeks to replace them with personal safety planning. The latter is an active and collaborative process in which the client agrees to address issues of risk and danger in incremental steps. Such planning teaches the significance of safety and provides the client with alternative means of selfregulation and self-management. Dissociation involves the alteration of consciousness, memory, personal information, and identity, items that are normally associated and integrated (American Psychiatric Association, 1994). Dissociation can be mild and transient or quite extensive, as seen in cases of ongoing abuse during childhood where it may be the abused child’s best way of coping. In adulthood as well as childhood, dissociative defenses—especially those that result in skips in ongoing conscious awareness, identity, and memory—may pose significant impediment to safety, as well as to general functioning. The client who actively dissociates to cope and/or who suffers from a major dissociative disorder has increased levels of risk. The use of dissociation as a primary coping style needs identification, a process that is often impeded by its covert nature and the clinician’s failure and/or inability to recognize it. Once it is recognized and identified, clients must learn alternative ways of being in relation to self and to the world. The clinician must be careful not to castigate the dissociative client nor to stigmatize the process. As with other coping skills developed in dire times and events, these skills were initially adaptive. Clients need to be shown how they have become maladaptive and actively taught other means of self-management and selfprotection. The process for clients diagnosed with dissociative identity disorder is more complicated and involves more technical interventions, which are beyond the scope of this article. Numerous resources are available on the treatment of dissociative identity disorder (Brenner, 2001; Kluft, 1996, 2002; Putnam, 1989; Ross, 1997; Schwartz, 2000). The development of safety may pose a special challenge to the addicted client whose safety may 419 This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Courtois be dependent upon becoming substance free. Special treatment programs for addicted survivors of complex trauma are now available and are all predicated upon safety (Miller & Guidry, 2001; Najavits, 2002; Triffleman, Carroll, & Kellogg, 1999). In fact, the one developed by Najavits is entitled “Seeking Safety.” Client education is also an integral component of Stage 1 treatment and should begin as early as possible in the process. First of all, education can be used to demystify the process of psychotherapy, something that might be terrifying to the client with CPTSD. Additionally, many traumatized individuals know nothing about trauma, may not label what happened to them as traumatic, and have little or no understanding that their symptoms may be related to their past experiences. Education about trauma and its impact is therefore important and may effectively help a client to understand his or her reactions and to develop increased self-understanding and self-compassion. Education is also the foundation for teaching specific skills that cover many domains: the identification and regulation of emotional states, personal mindfulness, self-care, life skills, coping skills, problem-solving, social skills, and decision-making. As noted by Gold (2000), these skills are often missing in chronically abusive and neglectful families. This skills-based approach is also promulgated in the dialectic behavior therapy model for borderline clients developed by Linehan (1993) and applicable to the complex trauma client. Education is used throughout the treatment process. The client must be motivated to change and must actively practice what is taught. Affect-regulation and modulation are perhaps the most important selfregulatory skills that the client needs to learn. Self-care and mind–body issues are related to all of the topics discussed in this section but need a focus in their own right. Many CPTSD clients are alienated from themselves, their general wellbeing, and their bodies (as well as their minds). The mind–body split experienced by these clients is often quite problematic, with the client in a more or less perpetual state of disconnect. As a result, many ignore their bodies, are neglectful regarding wellness and medical concerns, and put themselves at unnecessary risk in a variety of ways. As these issues are identified, the clinician may need to actively engage the client in paying attention to his or her bodily reactions and around 420 planning for general self-care, preventive medicine, and/or actual treatment. Treatment approaches that are “whole person” and that address issues of the body and mind under chronic stress have been developed in recent years to supplement an approach that, until just recently, tended to focus exclusively on the psychological realm (Levine, 1997; Ogden & Minton, 2000; Rothschild, 2000; Siegel, 1999). Psychopharmacology is another treatment for the related physical–psychological symptoms. As noted above, combined psychopharmacology and psychotherapy are recommended, including for CPTSD patients. Guidelines for the medical management of PTSD can be found in works by Foa et al. (1999; 2000a) and Friedman (2000; 2001). Having relationships with others and building support networks are crucial to address in this stage. As discussed earlier, mistrust is a major interpersonal hallmark of many CPTSD clients because of their experience with exploitive and nonprotective individuals. Social/relational deficits and problems have long been identified as a legacy of abuse trauma (Courtois, 1979a, 1979b; Finkelhor, 1990), a recognition that has been given additional emphasis in the past 2 decades by attachment researchers (Siegel, 1999). The insecure style is most associated with childhood abuse trauma and results in children and (later) adults whose attachment styles reflect what they learned in their relationships with primary caretakers: Some are excessively self-sufficient and/ or caretaking of others while others are constantly anxious and insecure. Those who were exposed to the most abusive and disorganized of family backgrounds often develop disorganized/ dissociative attachment styles (i.e., those involving shifting states of identity, emotional lability, shifting relationships with others, self-injury as a means of self-soothing, etc.). Historically, these have been long associated with the diagnosis of borderline personality. Clinicians must work directly with these various styles while providing a secure relational base within the treatment from which to acquire more interpersonal skills, including the ability to negotiate relationships and to develop intimacy with others. As this discussion of Stage 1 is wrapped up, the reader might be asking what happened to the focus on trauma and does any of it happen in this stage? Although this stage does not specifically focus on trauma processing and resolution, much of the work described above does, either directly This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Special Issue: Complex Trauma, Complex Reactions or indirectly, relate to traumatic antecedents. The major difference between this stage and the next is that, in Stage 1, the traumatic material is addressed predominantly from an educational/ cognitive perspective. The client is educated about trauma, short and long-term posttraumatic responses, and the developmental adaptations found to be associated with chronic and complex forms of trauma. Attachment and trauma-based cognitions are constantly attended to in this stage. Early research by Jehu, Klassen, and Gazan (1985) and more recent research by Roth and colleagues (e.g., Roth & Batson, 1997) have provided empirical support for this approach. It appears that changing abuse- and/or trauma-related cognitions can resolve negative self-perception to such a degree that the client can becomes less symptomatic. The client’s ongoing symptoms become the basis for determining whether more directed work with the trauma is needed. If the client remains symptomatic and is willing to work more directly on the trauma, treatment proceeds to Stage 2. Informed consent stresses that the trauma resolution work is just that, an attempt to process trauma, resolve impasses, and promote posttraumatic growth in the place of decline. Treatment of traumatic material and memories is in the interest of resolution and not in the interest of making or causing new memories to emerge, although that is something that might happen as the trauma is addressed more directly (Gold & Brown, 1997). At times, the shift into Stage 2 will be explicitly initiated by the clinician. At other times, it will be due to the collaborative evaluation of the client’s need and readiness for trauma processing. At still others, it will proceed rather seamlessly from some of the cognitive work that might move naturalistically to a discussion of feelings associated with the cognitive process. Connecting affectively with the trauma story and the trauma-based cognitions and behaviors within the context of a supportive relationship is a major focus of trauma processing (Fosha, 2003; Neborsky, 2003; Schore, 2003; Solomon & Siegel, 2003). Stage 2: Deconditioning, mourning, resolution, and integration of the trauma. Stage 2 utilizes exposure and narrative-based techniques to have the client directly address issues related to the trauma (the objective trauma story involving description of how it occurred, where, with whom, etc., along with the subjective reactions that occurred at the time and afterwards) and relies on the client’s utilizing the increased selfregulatory skills developed in Stage 1 without resorting to maladaptive defenses. At the present time, gradual as opposed to prolonged exposure and associated desensitization seem to be the choice most clinicians make, although this might change as more technical development occurs. Whatever exposure or narrative technique is selected, its pace and intensity need to be calibrated so as not to overwhelm. It must match the client’s capacity. Briere (2002b) has cautioned clinicians about exceeding what he labels the “therapeutic window,” or the client’s ability to feel without resorting to and reinstating old destructive behaviors such as self-injury, suicidality, and increased use of dissociation. Equally important in this stage is the clinician’s ability to stay with the client, that is, to hear the story in some detail, to provide safety by means of attachment security, and to emotionally resonate with the client. Whether the processing is formalized and utilizes a specialized approach or technique (e.g., eye movement desensitization and reprocessing, EMDR [Shapiro, 2001], guided imagery [Naperstek, 2004], imaginal rescripting [Smucker & Niederee, 1995], narrative telling/writing [Pennebaker, 2000], or sensorimotor approaches [Levine, 1997; Rothschild, 2000]) or occurs more naturalistically as the client comes to understand more about past events and their impact, other issues usually emerge that require therapeutic attention. For example, grief and mourning for all that was lost are common, as are strong feelings of shame and rage. Stage 2 work involves processing whatever emotions that emerge to the point of some resolution, in order for symptoms to diminish. During this stage, the client might undertake specific actions to resolve relationships with abusers or others. These might involve such actions as disclosures and discussions, boundary development, separation from or reconnection with others, all from a position of increased awareness and understanding and increased interpersonal as well as self-regulatory skills. Stage 3: Self and relational development, enhanced daily living. Although Stage 3 can be seen as the culmination of the previous work and as an exciting time of growth (Herman, 1992b), it may also be fraught with difficulty for some trauma survivors who have never had the opportunity for a life that is in the range of normal, even with the emphasis placed on life skills in 421 This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Courtois Stage 1. Stage 3 might be a time when the client, building upon the awareness developed in Stage 2, specifically realizes the dysfunction and pathology of the past as he or she continues to attempt to move beyond its influence. Stage 3 frequently involves work on unresolved developmental deficits and fixations and on fine-tuning the self-regulatory skills developed in Stage 1. Some of the issues that are most in evidence are the development of trustworthy relationships and intimacy, sexual functioning, parenting, career and other life decisions, ongoing decisions/ discussions with abusive others, and so forth. Specific resources are available for many of these issues (Basham & Miehls, 2004; Bass & Davis, 1994; Davis, 1991; Davis, 2002; Johnson, 2002; Maltz, 2001). In this stage, as in the others, the clinician continues to provide the secure base from which the client does the work and provides ongoing facilitation of relational learning. As noted earlier, the intensity and duration of the entire treatment will differ substantially. Some clients require treatment for years or even decades. Others may complete treatment in 6–12 months. The initial focus of safety, affect regulation, and skills development is designed to give all who enter treatment different tools with which to function in the world. At whatever point termination occurs, it poses special issues, stirring up feelings of abandonment, grief, fear, and loss of security. It is best for termination to be as collaborative as possible and to be clearly demarcated. The option should be left open for a return, whether for a check-in, booster, or a return to more sustained treatment. Clients can be prepared for the possibility of developmental triggers or other crises necessitating the need for a return to treatment. Because of the possibility of a patient’s return, it is recommended that no dual or outside relationships be developed posttermination (Herman, 1992b). References American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: Author. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. BASHAM, K. K., & MIEHLS, D. (2004). Transforming the legacy: Couple therapy with survivors of childhood trauma. New York: Columbia University Press. BASS, E., & DAVIS, L. (1994). The courage to heal: A guide for women survivors of child sexual abuse (3rd ed.). New York: Harper & Row. 422 BERNSTEIN, E. M., & PUTNAM, F. W. (1986). Development, reliability, and validity of a dissociation scale. Journal of Nervous and Mental Disease, 174, 727–735. BLAKE, D. D., WEATHERS, F. W., NAGY, L. M., KALOUPEK, D. G., CHARNEY, D. S., & KEANE, T. M. (1996). The Clinician-Administered PTSD Scale (CAPS). Boston: National Center for PTSD, Boston VA Medical Center. BRENNER, I. (2001). Dissociation of trauma: Theory, phenomenology, and technique. Madison, CT: International Universities Press. BRIERE, J. (1984). The effects of childhood sexual abuse on later psychological functioning: Defining a post-sexual abuse syndrome. Paper presented at the Annual Convention of the American Psychological Association, Toronto, Ontario, Canada. BRIERE, J. (1987). Post-sexual abuse trauma: Data and implications for clinical practice. Journal of Interpersonal Violence, 2, 367–379. BRIERE, J. (1992). Child abuse trauma: Theory and treatment of the lasting effects. Newbury Park, CA: Sage. BRIERE, J. (1995). Trauma Symptom Inventory (TSI) professional manual. Odessa, FL: Psychological Assessment Resources. BRIERE, J. (2000a). Cognitive Distortions Scale (CDS). Odessa, FL: Psychological Assessment Resources. BRIERE, J. (2000b). Inventory of Altered Self Capacities (IASC). Odessa, FL: Psychological Assessment Resources. BRIERE, J. (2001). Detailed Assessment of Posttraumtic Stress (DAPS). Odessa, FL: Psychological Assessment Resources. BRIERE, J. (2002a). Multiscale Dissociation Inventory (MDI). Odessa, FL: Psychological Assessment Resources. BRIERE, J. (2002b). Treating adult survivors of severe childhood abuse and neglect: Further development of an integrative model. In L. Myers, J. Berliner, C. T. Briere, T. Hendrix, C. Reid, & C. Jenny (Eds.), The APSAC handbook on child maltreatment (2nd ed., pp. 175–202). Newbury Park: Sage. BRIERE, J. (2004). Psychological assessment of adult posttraumatic states (2nd ed.). Washington, DC: American Psychological Association. BRIERE, J., ELLIOT, D., HARRIS, K., & COTMAN, A. (1995). Trauma symptom inventory: Psychometrics and association with childhood and adult victimization in clinical samples. Journal of Interpersonal Trauma, 10, 387–401. BRIERE, J., & SPINAZZOLA, J. (in press). Phenomenology and psychological assessment of complex posttraumatic states. Journal of Traumatic Stress. BURGESS, A. W., & HOLMSTROM, L. L. (1974). Rape trauma syndrome. American Journal of Psychiatry, 131, 981–986. CARLSON, E. B. (1997). Trauma assessments: A clinician’s guide. New York: Guilford Press. CARLSON, E. B., & PUTNAM, W. (1993). An update on the Dissociative Experiences Scale. Dissociation, 6, 16–27. CHU, J. A. (1992). The therapeutic roller coaster: Dilemmas in the treatment of childhood abuse survivors. Journal of Psychotherapy Practice and Research, 1, 351–370. CHU, J. A. (1998). Rebuilding shattered lives: The responsible treatment of complex post-traumatic and dissociative disorders. New York: Wiley. CLOITRE, M. (2002, November). A randomized control trial of phase oriented treatment of childhood abuse survivors with PTSD. Paper presented at the Proceedings of the Annual Convention of the International Society for Traumatic Stress Studies, Baltimore, MD. This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Special Issue: Complex Trauma, Complex Reactions CLOITRE, M., KOENEN, K. C., COHEN, L. R., & HAN, H. (2002). Skills training in affective and interpersonal regulation followed by exposure: A phase-based treatment for PTSD related to childhood abuse. Journal of Consulting and Clinical Psychology, 70, 1067–1074. COURTOIS, C. A. (1979a). Characteristics of a volunteer sample of adult women who experienced incest in childhood and adolescence. Dissertation Abstracts International, 40A, Nov–Dec, 3194-A. COURTOIS, C. (1979b). The incest experience and its aftermath. Victimology: An International Journal, 4, 337–347. COURTOIS, C. A. (1988). Healing the incest wound: Adult survivors in therapy. New York: Norton. COURTOIS, C. A. (1995). Assessment and diagnosis. In C. Classen & I. D. Yalom (Eds.), Treating women molested in childhood: A volume in the Jossey-Bass library of current clinical technique (pp. 1–34). San Francisco: Jossey-Bass. COURTOIS, C. A. (1999). Recollections of sexual abuse: Treatment principles and guidelines. New York: Norton. COURTOIS, C. A., & JAY, J. (1998). Trauma responsive therapy: A shift in perspective. Centering: Newsletter of The CENTER: Posttraumatic Disorders Program, 3(5), pp. 1, 8. DAVIS, L. (1991). Allies in healing: When the person you love was sexually abused as a child. New York: Harper Perennial. DAVIS, L. (2002). I thought we’d never speak again. New York: HarperCollins. DELL, P. F., DALENBERG, C. J., FRANKEL, A. S., & CHEFETZ, R. A. (2003, November). A tutorial on clinical assessment of dissociative patients: Creating a standard assessment battery. Paper presented at the Annual Conference of the International Society for the Study of Dissociation, Chicago, IL. FINKLEHOR, D. (1984). Child sexual abuse: New theory and research. New York: Free Press. FINKELHOR, D. (1985). The traumatic impact of child sexual abuse: A conceptualization. Journal of Orthopsychiatry, 55, 530–541. FINKELHOR, D. (1990). Early and long-term effects of child sexual abuse: An update. Professional Psychology: Research and Practice, 21, 325–330. FOA, E. B. (1995). Posttraumatic Stress Diagnostic Scale (PDS). Minneapolis, MN: National Computer Systems. FOA, E. B., DAVIDSON, J. R. T., & FRANCES, A. (1999). Expert consensus guideline series. The Journal of Clinical Psychiatry, 60 (Suppl. 16, Treatment of Posttraumatic Stress Disorder). FOA, E. B., KEANE, T. M., & FRIEDMAN, M. J. (Eds.). (2000a). Effective treatments for PTSD: Practice guidelines from the International Society for Traumatic Stress Studies. New York: Guilford Press. FOA, E. B., KEANE, T. M., & FRIEDMAN, M. J. (2000b). Introduction. In E. B. Foa, T. M. Keane, & M. J. Friedman (Eds.), Effective treatment for PTSD (pp. 1–17): New York: Guilford Press. FORD, J. D. (1999). PTSD and disorders of extreme stress following war zone military trauma: Comorbid but distinct syndromes? Journal of Consulting and Clinical Psychology, 67, 3–12. FORD, J. D., COURTOIS, C. A., STEELE, K., VAN DER HART, O., & NIJENHUIS, E. R. S. (in press). Treatment of complex sequelae of psychological trauma. Journal of Traumatic Stress. FORD, J. D., & KIDD, P. (1998). Early childhood trauma and disorders of extreme stress as predictors of treatment outcome with chronic PTSD. Journal of Traumatic Stress, 11, 743–761. FOSHA, D. (2003). Dyadic regulation and experiential work with emotion and relatedness in trauma and disorganized attachment. In M. F. Solomon & D. J. Siegel (Eds.), Healing trauma: Attachment, mind, body, and brain (pp. 221–281). New York: Norton. FRIEDMAN, M. J. (2000). A guide to the literature on pharmacology for PTSD. PTSD Research Quarterly, 11, 1–7. FRIEDMAN, M. J. (2001). Allostatic versus empirical perspectives on pharmacotherapy. In J. Wilson, M. J. Friedman, & J. Lindy (Eds.), Treating psychological trauma & PTSD. New York: Guilford Press. GOLD, S. N. (2000). Not trauma alone: Therapy for child abuse survivors in family and social context. Philadelphia: Taylor & Francis. GOLD, S. N., & BROWN, L. S. (1997). Therapeutic responses to delayed recall: Beyond recovered memory. Psychotherapy: Theory, Research, Practice, Training, 34, 182–191. HERMAN, J. L. (1992a). Complex PTSD: A syndrome in survivors of prolonged and repeated trauma. Journal of Traumatic Stress, 5, 377–391. HERMAN, J. L. (1992b). Trauma and recovery: The aftermath of violence—From domestic to political terror. New York: Basic Books. HERMAN, J. L., & HIRSCHMAN, L. (1977). Father-daughter incest. Signs: Journal of Women in Culture and Society, 2, 735–756. HERMAN, J. L., PERRY, J. C., & VAN DER KOLK, B. A. (1989). Childhood trauma in borderline personality disorder. American Journal of Psychiatry, 146, 490–495. H OROWITZ , M. J. (1976). Stress response syndromes. Northvale, NJ: Jason Aronson. JANET, P. (1925). Psychological healing. New York: Macmillan. (Original published 1919) JEHU, D., KLASSEN, C., & GAZAN, M. (1985). Cognitive restructuring of distorted beliefs associated with childhood sexual abuse. Journal of Social Work and Human Sexuality, 4, 49–69. JOHNSON, S. (2002). Emotionally focused couple therapy with trauma survivors: Strengthening attachment bonds. New York: Guilford Press. KARDINER, A. (1941). The traumatic neuroses of war [Monograph]. In Psychosomatic Medicine. Washington, DC: National Research Council. KEPNER, J. I. (1995). Healing tasks: Psychotherapy with adult survivors of childhood abuse. San Francisco: Jossey-Bass. KLUFT, R. P. (1994). Treatment trajectories in multiple personality disorder. Dissociation, 7, 63–76. KLUFT, R. P. (1996). Outpatient treatment of dissociative identity disorders and allied forms of dissociative disorders not otherwise specified in children and adolescents. Child and Adolescents Psychiatric Clinics of North America, 5, 471–494. KLUFT, R. P. (2002). The difficult to treat patient with a dissociative disorder. In J. M. Dewan & R. W. Pies (Eds.), The difficult-to-treat psychiatric patient (pp. 209–242). Washington, DC: American Psychiatric Press. KORN, D., & LEEDS, A. M. (2002). Preliminary evidence of efficacy for EMDR resource development and installation in the stabilization phase of treatment of complex posttrau- 423 This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Courtois matic stress disorder. Journal of Clinical Psychology, 58, 1465–1487. KROLL, J. (1993). PTSD/borderlines in therapy: Finding the balance. New York: Norton. LEEDS, A. M., & SHAPIRO, F. (2000). EMDR and resource installation: Principles and procedures for enhancing current functioning and resolving traumatic experiences. In J. Carlson & L. Sperry (Eds.), Brief therapy strategies with individuals and couples (pp. 469–534). Phoenix, AZ: Zeig, Tucker & Thisen. LEVINE, P. A. (1997). Waking the tiger: Healing trauma. Berkeley, CA: North Atlantic Books. LINEHAN, M. (1993). Cognitive–behavioral treatment of borderline personality disorder. New York: Guilford Press. LOEWENSTEIN, R. J. (1991). An office mental status examination for complex chronic dissociative symptoms and multiple personality disorder. Psychiatric Clinics of North America, 14, 567–604. MALTZ, W. (2001). The sexual healing journey: A guide for survivors of sexual abuse. New York: Quill. MCDONAGH-COYLE, A., FORD, J. D., & DEMMENT, C. (2002, November). Development and initial evaluation of brief integrative therapy. Paper presented at the International Society for Traumatic Stress Studies, Baltimore, MD. MILLER, D., & GUIDRY, L. (2001). Addictions and trauma recovery: Healing the body, mind & spirit. New York: Norton. NAPERSTEK, B. (2004). Invisible heroes: Survivors of trauma and how they heal. New York: Bantam. NAJAVITS, L. (2002). Seeking safety: A treatment manual for PTSD and substance abuse. New York: Guilford Press. NEBORSKY, R. J. (2003). A clinical model for the comprehensive treatment of trauma using an affect experiencingattachment theory approach. In M. F. Solomon & D. J. Siegel (Eds.), Healing trauma: Attachment, mind, body, and brain (pp. 282–321). New York: Norton. NEWMAN, E., ORSILLO, S. M., HERMAN, D. S., NILES, B. L., & LITZ, B. (1995). The clinical presentation of disorders of extreme stress in combat veterans. Journal of Nervous and Mental Disease, 183, 664–668. NIJENHUIS, E. (2000). Somatoform dissociation: Major symptoms of dissociative disorders. Journal of Trauma and Dissociation, 1, 7–32. OGDEN, P., & MINTON, K. (2000). Sensorimotor psychotherapy: One method for processing trauma. Traumatology, 6(3), Article 3. Available at http://www.fsu.edu/∼trauma/ v6i3/v6i3a3.html PEARLMAN, L. A. (2001). The treatment of persons with complex PTSD and other trauma-related disruptions of the self. In J. P. Wilson, M. Friedman, & J. Lindy (Eds.), Treating psychological trauma and PTSD (pp. 205–236). New York: Guilford Press. PEARLMAN, L. A. (2003). Trauma and Attachment Belief Scale (TABS) manual. Los Angeles: Western Psychological Services. PELCOVITZ, D., & KAPLAN, S. (1995, July). Psychological characteristics of battered women: Complex posttraumatic stress disorder in partner abuse. Paper presented at the Family Violence Conference, Durham, NH. PELCOVITZ, D., VAN DER KOLK, B. A., ROTH, S., MANDEL, F. S., KAPLAN, S., & RESICK, P. A. (1997). Development of a criteria set and a structured interview for disorders of extreme stress (SIDES). Journal of Traumatic Stress, 10, 3–17. 424 PENNEBAKER, J. W. (2000). The effects of traumatic disclosure on physical and mental health. In J. Violante & D. Paton (Eds.), Posttraumatic stress intervention (pp. 97–114). Springfield, IL: Charles C Thomas. PUTNAM, F. W. (1989). Diagnosis and treatment of multiple personality disorder. New York: Guilford Press. RESICK, P. NISHITH, P., & GRIFFIN, M. (2003). How well does cognitive–behavioral therapy treat symptoms of complex PTSD? An examination of child sexual abuse survivors within a clinical trial. CNS Spectrums, 8, 340–343, 351–355. ROSS, C. A. (1997). Dissociative identity disorder: Diagnosis, clinical features, and treatment of multiple personality. New York: Wiley. ROSS, C. A., HEBER, S., NORTON, G. R., ANDERSON, D., ANDERSON, G., & BARCHET, P. (1989). The Dissociative Disorders Interview Schedule: A structured interview. Dissociation, 2(3), 169–189. ROTH, S., & BATSON, R. (1997). Naming the shadows: A new approach to individual and group psychotherapy for adult survivors of childhood incest. New York: Free Press. ROTH, S., PELCOVITZ, D., VAN DER KOLK, B. A., & MANDEL, F. (1997). Complex PTSD in victims exposed to sexual and physical abuse: Results from the DSM–IV field trials for posttraumatic stress disorder. Journal of Traumatic Stress, 10, 539–555. ROTHSCHILD, B. (2000). The body remembers: The psychophysiology of trauma and trauma treatment. New York: Norton. SAAKVITNE, K. W., GAMBLE, S. G., PEARLMAN, L. A., & LEV, B. (2000). Risking connection: A training curriculum for working with survivors of childhood abuse. Lutherville, MD: Sidran Foundation Press. SCHORE, A. N. (2003). Affect regulation and the repair of the self. New York: Norton. SCHWARTZ, H. L. (2000). Dialogues with forgotten voices: Relational perspectives on child abuse trauma and treatment of dissociative disorders. New York: Basic Books. SHAPIRO, F. (2001). Eye movement desensitization and reprocessing: Basic principles, protocols, and procedures. New York: Guilford Press. SIEGEL, D. J. (1999). The developing mind: Toward a neurobiology of interpersonal experience. New York: Guilford Press. SMUCKER, M. R., & DANCU, C. V. (1999). Cognitive–behavioral treatment for adult survivors of childhood trauma: Imagery rescripting and reprocessing. Northvale, NJ: Jason Aronson. SMUCKER, M. R., & NIEDEREE, J. (1995). Treating incestrelated PTSD and pathogenic schemas through imaginal exposure and rescripting. Cognitive and Behavioral Practice, 2, 63–93. SOLOMON, M., & SIEGEL, D. (2003). Healing trauma: Attachment, mind, body, and brain. New York: Norton. STEINBERG, M. (1994). Interviewer’s guide to the Structured Clinical Interview for DSM–IV Dissociative Disorders— Revised (SCID–D–R). Washington, DC: American Psychiatric Press. TEDESCHI, R. G., & CALHOUN, L. G. (1995). Trauma and transformation: Growing in the aftermath of suffering. Thousand Oaks, CA: Sage. TRIFFLEMAN, E., CARROLL, K., & KELLOGG, S. (1999). Substance dependence posttraumatic stress disorder therapy: This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Special Issue: Complex Trauma, Complex Reactions An integrated cognitive behavioral approach. Journal of Substance Abuse Treatment, 17, 3–14. VAN DER HART, O., BROWN, P., & VAN DER KOLK, B. A. (1989). Pierre Janet’s treatment of post-traumatic stress. Journal of Traumatic Stress, 2, 379–395. VAN DER KOLK, B. A. (1999). The self-report inventory for disorders of extreme stress (SIDES-SR). Unpublished manuscript. VAN DER KOLK, B. A., DREYFUSS, D., MICHAELS, M., SHERA, D., BERKOWITZ, R., FISLER, R., & SAXE, G. (1994). Fluoxetine in posttraumatic stress disorder. Journal of Clinical Psychiatry, 55, 517–522. VAN DER KOLK, B. A., PERRY, J. C., & HERMAN, J. L. (1991). Childhood origins of self-destructive behavior. American Journal of Psychiatry, 148, 1665–1671. WALKER, L. E. (1979). The battered woman. New York: Harper & Row. WALKER, L. E. (1984). The battered woman syndrome. New York: Springer. WEISS, D. S., & MARMAR, C. R. (1997). The Impact of Event Scale—Revised. In J. P. Wilson and T. M. Keane (Eds.), Assessing psychological trauma and PTSD (pp. 399–411). New York: Guilford Press. WILSON, J. P., & KEANE, T. M. (2004). Assessing psychological trauma and PTSD (2nd ed.). New York: Guilford Press. World Health Organization. (1994). The ICD-10 classification of mental and behavioral disorders: Clinical descriptions and diagnostic guidelines. Geneva, Switzerland: Author. ZANARINI, M. C. (Ed.). (1997). Role of sexual abuse in the etiology of borderline personality disorder. Washington, DC: American Psychiatric Press. ZLOTNICK, C., & PEARLSTEIN, T. (1997). Validation of the Structured Interview for Disorders of Extreme Stress. Comprehensive Psychiatry, 38, 243–247. 425
Purchase answer to see full attachment
Explanation & Answer:
3 pages
User generated content is uploaded by users for the purposes of learning and should be used following Studypool's honor code & terms of service.

Explanation & Answer

Attached.

Running head: DOMESTIC VIOLENCE AND CHILD TRAUMA

Domestic Violence and Child Trauma
Name
Course
Date

1

DOMESTIC VIOLENCE AND CHILD TRAUMA

2

Introduction
Domestic violence remains one of the major social issues that exist in society today.
While available data suggest that domestic violence has been on a decline, it remains prevalent
across the world. While both men and women are affected by gender violence, women are
majorly affected. According to the World Health Organization (WHO), about one in three
women worldwide have experienced either physical and/or sexual intimate partner violence
(WHO, 2017). Globally, 30% of women who have been in an intimate relationship have reported
experiencing some form of domestic violence from an intimate partner. The United Nations
(2019) further notes that 38% of murders of women globally are as a result of violence
perpetrated by an intimate partner. Within the United States, the National Coalition Against
Domestic Violence (NCADV) reports that approximately 20 people are physically abused per
minute by an intimate partner (NCADV, 2019). With most of this violence occurring in homes
and shelters where children are housed, Fantuzzo and Fusco (2007) note that millions of these
children become exposed to the practice. Such children are often at a threat of long-term physical
and mental health problems as a result of trauma associated with domestic violence. This paper
discusses the effects of trauma as a result of domestic violence on children, its causes, and
psychological strategies of treating children affected by the phenomena.
Statistics of Children Affected by Domestic Violence
Existing data shows that domestic violence remains a global problem with some culture,
encouraging it. In describing the magnitude of children and domestic violence, Fantuzzo and
Fusco (2007); Elghossain et al. (2019) notes that about 4 of 10 (43 percent) women who
experience violence from an intimate partner live in homes and shelters with children aged under
12. This figure is even higher in third-world and developing countries. Globally, the United

DOMESTIC VIOLENCE AND CHILD TRAUMA

3

Nations (UN) estimates that close to 300 million children are exposed to violence at home (UN,
2019). In the US alone, close to 16 million children live in homes experiencing domestic
violence, with half of these living in homes where violence can be described as severe. On any
given day, close to 14,000 children live in homes and shelters where domestic violence occurs.
In these cases, WHO (2017) note t...


Anonymous
Just what I was looking for! Super helpful.

Studypool
4.7
Trustpilot
4.5
Sitejabber
4.4

Similar Content

Related Tags