Treatment of Complex or Childhood Trauma
The increasing number of returning veterans has helped to raise public awareness of the effects of trauma on mental health. Post-traumatic stress disorder (PTSD) can set in after exposure to an extremely frightening event, and it is characterized primarily by anxiety symptoms.
However, repeated trauma, over a long period of time, can result in much more diffuse psychological problems that can affect every area of life. This is particularly true when the traumatic circumstances take place during early life. For example, victims of childhood sexual abuse are much more likely to develop borderline personality disorder. Victims of repeated or systematic violence in youth are at greater risk for antisocial personality disorder, or psychopathy. An individual’s response to these types of trying conditions in early life depends on genetic predisposition, protective factors such as supportive relationships, and the influence of chance events.
Based on various combinations of these factors, I have seen survivors of childhood abuse who presented with various personality disorders, dissociative disorders, chronic depression or anxiety, substance abuse, eating disorders, somatization or pain disorders such as chronic intractable migraine, and anything in between. Essentially, until the primary injury is healed, the trauma victim remains more susceptible to problems throughout the lifespan.
Adult Attachment Functioning and the Treatment of Complex Trauma
One of the best models for understanding the impact of early experiences on adult psychological functioning is attachment theory. The central concept of this model is that each person develops a core expectation about how important people in their life will treat them. People who develop realistic and generally positive expectations have a secure attachment style, while those whose early attachment figures were unreliable, disappointing, or malicious develop attachment styles that are anxious, dismissive, or confused. Attachment style forms by around age 2, and remains extremely stable throughout the lifespan. However, new research has shown that targeted psychological treatment can correct disordered attachment, allowing people who have never been able to experience satisfying, secure relationships to gain that ability.
Additionally, disruptions in attachment functioning create a vulnerability to the development of a wide variety of psychological problems, putting individuals with difficult personal histories at high risk for the development of serious, recurrent mental illness. By correcting this root problem, ailments such as PTSD, bipolar disorder, depression, and anxiety can be permanently resolved.
It is unfortunate that so many modern psychological treatments have adopted a medical model, focusing on the resolution of symptoms rather than addressing the underlying causes. Too often, this results in poor long-term treatment outcomes, symptoms that resolve only to return or transform into something else. People end up coming to think of themselves as “patients,” permanently enmeshed in a system of healthcare that provides ineffective psychological interventions and mind-numbing medications.
A Holistic Trauma Treatment Model
In order to treat complex and childhood trauma effectively, several aspects must be addressed: affect regulation, presenting symptoms, and underlying psychological dynamics such as disrupted attachment.
A major problem with complex trauma is emotional dysregulation. You get a lot of mood swings, irritability, impulsiveness, even suicide attempts. The basic skills for regulating emotion are tied in to attachment functioning, and until a person has a chance to develop a solid internal working model of a reliable attachment figure, they’ll continue to have trouble keeping their emotions under control. I tend to introduce relaxation techniques and mindfulness exercises in the early stages of treatment, as these can provide some concrete tools for getting a better handle on emotions until the underlying problems are resolved.
The presenting symptoms for this type of trauma can run the gamut of psychological disorders, so the treatment must be tailored to the individual. I take an integrative approach, using cognitive-behavioral, solution-focused, and strategic treatments as needed. Many people make the mistake of attempting to resolve the symptoms without addressing the underlying dynamics. As the great Dr. Milton H. Erickson noted, in many cases, the symptom is a solution. The key to providing relief is to provide better solutions.
In order to address the underlying dynamics, I generally build upon early successes with the above techniques to gradually incorporate more dynamic psychotherapy techniques which require more time and trust, such as relational, ego state, or gestalt therapies. I often use hypnosis to enhance the effectiveness of these therapies, and find that this can help patients to effect changes that are far-reaching, rapid, and stable.