Despite these shifts in orientation understanding the aftereffects and their origins, the individuals with CPTSD/DESNOS (or BPD) diagnosis can be a difficult population to treat. Psychotherapy is fraught with many complications (Chu, 1992; Linehan, 1993) due to the number of issues symptoms the client might experience, issues with personal safety, and deficiencies in the ability to regulate affect and to apply other life skills.; Exposing these patients clients too directly to their trauma history in the absence of their ability to maintain safety in their lives or to self-regulate strong emotions can lead to retraumatization, and associated decompensation, and inability to function.
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 research support has become available (Foa, Friedman, Keane, Friedman, & Cohen, 2008). The research substantiation of the effectiveness of these techniques in ameliorating the often refractory symptoms of PTSD is laudable. Unfortunately, the wholesale application use of CBT exposure techniques to in patients with CPTSD/DESNOS (even those who clearly have PTSD symptoms) may be problematic if applied too early in treatment and before the client is stable and safe.
CPTSD/DESNOS (even those who clearly meet criteria for PTSD) may be problematic and resurface some of the problems described in the previous paragraph. In response to this, the recommended course of treatment from those experienced in treating CPTSD (Chu, 1998; Courtois, 1999, 2004; Courtois, Ford, & Cloitre, 2009; Ford, Courtois, Van der Hart, Nijenhuis, & Steele, 2005) involves the sequencing of healing tasks across several main stages of treatment. These stages include (1) pre-treatment assessment, (2) early stage of safety, education, stabilization, skill-building, and development of the treatment alliance, (3) middle stage of trauma processing and resolution, and (4) late stage of self and relational development and life choice. There is overlapping therapeutic work throughout the stages and often a need to rework stabilization skills over the course of treatment. But as each stage builds on the previous work, the trauma survivor acquires growing control and mastery, which directly counteract the powerlessness of victimization and its continuing aftereffects.
The pre-treatment assessment should be comprehensive, with attention to diagnosis within the posttraumatic/dissociative spectrum, posttraumatic and other symptoms, safety, and comorbidity (particularly substance abuse, medical illness, eating disorders, and affective disorders). It is useful to complete all five axes of the DSM, with emphasis on current stressors and available resources for use in the development of a treatment plan. This is also the time to take a broad look at needs and resources, including available health care resources, which can so easily be limited by a client’s disability or by managed care insurance coverage or by his/her own motivation or emotional capacity for treatment.
The early stage focuses on safety, stabilization, and establishing the treatment frame and the therapeutic alliance. Measured by mastery of the necessary skills and not by duration, this stage of treatment may be the most important since it is directly related to the clients’ capacity to function. Education in complex trauma and elements of the human response to trauma provide a foundation for skill-building. Skills to be developed include healthy boundaries, safety planning, assertiveness, self-nurturing and self-soothing, emotional modulation, and strategies to contain trauma symptoms such as spontaneous flashbacks and dissociative episodes. Additionally, attention to wellness, stress management and any medical/ somatic concerns is needed. Medications such as antidepressants and anti-anxiety drugs are often helpful and should be considered to target posttraumatic symptoms and those associated with depression, anxiety, and sleep disorders.
Christine A Courtois, PhD & Associates, PLCis a private practice that specializes in the treatment of adults experiencing the effects of childhood incest/sexual abuse and other types of trauma. Dr. Courtois has worked with these issues for 30 years and has developed treatment approaches for complex posttraumatic and dissociative conditions for which she has received international recognition.
For more information: www.drchristinecourtois Email: CACourtoisPhD@aol.com