This is lecture 1 of a 10 week Lecture series for Level 6 students Introducing them to Complex Trauma. This module is based on Courtis & Ford (2013) Treatment of Complex Trauma : A sequenced relationship based approach.London. Guildford Press.

1. Lecture 1 : Introduction to
Complex Trauma
Module: Complex case work.
Kevin Standish

2. Overview
1.
2.
3.
4.
Learning outcomes
Trauma
Defining and understanding complex trauma
Complex trauma: common emotions and
reactions
5. Three primary domains in complex trauma
disorders
6. Readings

4. 1. To define complex trauma and responses.
2. Differentiate complex trauma from PTSD
3. Explore their own reactions to acute trauma, abuse and
violence.
4. Introduction of case studies
1. LEARNING OUTCOMES

5. 1.
2.
3.
4.
Through Our Eyes: Children, Violence, and Trauma
introductory stories of Doris and Hector
Safety and self disclosure
Trauma: DSM
2. TRAUMA

6. 2.1.Through Our Eyes: Children,
Violence, and Trauma
 http://www.youtube.com/watch?v=z8vZxDa2K
PM

7. 2.2.Introductory stories of Doris
and Hector
 Doris: 40-year-old woman sought therapy because has been gave
her an ultimatum.Doris has long been unable to trust anyone close
to her, yet is terrified of being abandoned.
 She switches between being highly dependent on a husband
wanting emotional and physical closeness, and then distancing and
pushing him away. This resulted in confusion for him leading him
to withdraw confirming her belief that you will never find anyone
trustworthy
 Doris’s mother suffered from schizophrenia resulting in repeated
hospitalisations. Doris was placed with relatives during these
hospitalisations. When her mother was at home she was
inconsistent in her emotional state and parenting behaviour.
Doris’s father was sexually and physically abusive. Doris’s father
blamed Doris for all her mother’s problems. Doris Kemp to believe
she ruined every relationship and harmed every person she cared
about

8. Hector
 Hector is a 21-year-old admitted to an inpatient unit
for being suicidal. He is the son of refugee parents who
fled the country following torture of the Father by the
authorities. Hector’s father PTSD behaviour resulted in
violence abuse and drinking within the family.
 At school Hector was bullied for being the teacher’s pet
and working hard at school. The parish priest
befriended him which later lead to sexual abuse.
 Whilst in the military he was sexually gang raped by
group of soldiers who assumed him to be gay.
 Following his military discharge he started drinking
heavily as it believed he was a monster and disgusting
resulting in frequent suicide attempts

9. 2.3.Safety and self disclosure
 This module may well trigger traumatic memories and students
who have experienced trauma.
 This may become a distressing and unsettling. Please ensure you
gain the appropriate support should this occur.
 If you should choose to share and disclose information regarding
personal trauma please do so with care and caution. This is a
teaching environment not a therapeutic environment.
 All students are to treat disclosures with respect and
confidentiality throughout this module

10. 2.4.Trauma: DSM
2.4.1 PTSD criteria
2.4.2 Definition
2.4.3.Original Trauma definition
2.4.4.Type1 & Type 2 trauma
2.4.5.Complex trauma not included in the DSM

11. 2.4.1.PTSD criteria
 Intrusive symptoms
 Avoidance symptoms
 Alterations in
cognitions and mood
 Alteration and
arousal and reactivity

12. 2.4.2.Definition of trauma
 Multiple meanings: referring to medical, physical
or psychological injury
 Difficult to find a clear definition of
psychological trauma
 Trauma is used interchangeably with the event
itself, or the individual's experience to the
event, or their response to the event
 Consistency in definition: stressor event:
psychological or psychic trauma/stressor
 Response to trauma: post-traumatic reactions or
complex traumatic stress disorders

13. 2.4.3. Original trauma definition
 Trauma was originally considered to be
abnormal experience: "outside the range
of normal experience"
 Evidence demonstrates that the majority
of adults and substantial minority of
children are exposed to traumatic events

14. 2.4.4. Type1 & Type 2 trauma
 Type 1: single incident trauma "out of the
blue": natural disaster, terrorist attack,
dramatic accident
 Type 2: complex or repetitive trauma:
ongoing abuse, domestic violence, community
violence, war or genocide. Usually involved
fundamental betrayal of trust in primary
relationships and compromises bio psycho
social and emotional development

15. 2.4.5.Type 2: sub-categories
 Type 2A: multiple traumas experienced by
individuals from relatively stable backgrounds
who have sufficient resources to manage
traumatic events better
 Type 2B: multiple traumas which so
overwhelming that individual cannot separate
one from the other, resilience is impaired.
Type 2 B(R) those who had resilience in the
beginning and type 2B(nR) those who never had
any resileince.

16. 1. Complex psychological
trauma
2. Complex traumatic stress
disorders
3. Proposed DSM criteria
3. DEFINING AND
UNDERSTANDING COMPLEX
TRAUMA

17. 3.1.Complex psychological
trauma
 Exposure to severe stresses that repetitive or prolonged,
 Involves harm or abandonment by caregivers or other
responsible adults
 Occur at developmentally vulnerable times in the
victim's life such as early childhood or adolescence
 In addition to being life-threatening or terrifying, these
experiences chronic and compromise development and
primary relationships


18. Complex trauma is defined
as traumatic attachment that is life or
self threatening, sexually violating,
emotionally overwhelming,
abandoning or personally negating
and involves events and experiences
that alter the development of the self,
by requiring survival take precedence
over normal psychobiological
development.

19. 3.2.Complex traumatic stress
disorders
 Changes in the mind, emotions, body and
relationships experienced following complex
trauma include
 Severe problems with the dissociation, emotional
dysregulation, somatic distress, and alienation
 Complex stress disorders go well beyond the
classic definition of what is traumatic in terms of
DSM and ICD 10

20. 3.3.Proposed DSM criteria








Alterations in the regulation of affective impulses
Alterations in attention and consciousness
Alterations in self perception
Alterations in perception of the perpetrator
Alterations in relationship to others
Somatisation and medical problems
Alterations in systems of meaning
Read: Understanding Complex Trauma, Complex
Reactions, and Treatment Approaches:
http://www.giftfromwithin.org/html/cptsdunderstanding-treatment.html

21. 1. Anxiety reactions
2. Depressive reactions
3. Anger and rage reactions
4. Self enstrangment and emotional deadness
5. Diffuse physical symptoms and depersonalisation
4. COMPLEX TRAUMA: COMMON
EMOTIONS AND REACTIONS

23. 4.1.Anxiety reactions
 These include fear, terror, apprehension,
hypervigilance, panic attacks, sleep
disturbance and nightmares
 Various phobias
 full range of anxiety disorders
 Physiological hyper-arousal alternating with
hypo-arousal

24. 4.2.Depressive reactions
 Show up in a variety of ways: ongoing diffuse
sadness and hopelessness with despair
 the inability to feel interest in and the
enjoyment of most life activities
 social detachment: not feeling close to other
people
 Not feeling any emotion other than vague sense
of flatness frustration or irritability (alexithymia)
 A feeling of an internal void or sense of emptiness
 self harm behaviour, chronic suicidal ideation
and sporadic suicide attempts

25. 4.3.Anger and rage reactions
 They struggle with intense feelings of anger and
rage ranging from an ongoing sense of irritability,
annoyance, disappointment, discussed, contempt
and frustration with themselves and others
 alternating with episodes of uncontrollable rage,
impulsive acts of protest and aggression
 self-directed in the form of self defeating
behaviour, self harm substance abuse and acting
out
 or by directing it at others through passive
aggressive, aggressive and violent behaviour

26. 4.4. Self enstrangment and emotional
deadness
 A common denominator linking these emotions is
a sense of self estrangement and emotional
deadness
 Anxiety is also based on the fear that if feelings
were allowed to emerge, they would be so
intense that they would result in the
victimisation of others, going crazy, causing
others to abandon them, or committing
suicide/homicide
 Depressive feelings tend to be based on the
experience of “black hole” or a “yearning void”
of emptiness, badness and despair

27. 4.5.Diffuse physical symptoms
and depersonalisation
 When emotions have been internalised as personally
intolerable it is not surprising these reactions develop
into a range of physical reactions
 somatoform disorders are manifestations of distress:
stomach problems, breathing problems, muscular
tension problems, high blood pressure, tinnitus, eating
disorders, headaches.
 These often defiant or muddle medical diagnosis but
are debilitating and real illnesses and health
impairment
 Trauma survivors experienced physical sensations as
dangerous and toxic; being interpreted as signs of
painful, frightening, confusing, rather than illnesses

28. 1. Emotion dysregulation
2. Loss of self integrity and self integration (dissociation)
3. Compromised relationship with others
5.THREE PRIMARY DOMAINS IN
COMPLEX TRAUMA DISORDERS

29. 5.1.Emotion dysregulation
 trauma survivors have difficulty coping with emotional
responses in reaction to everyday life events. Emotions
typically exceed the ability to regulate them because
the skills for such modulation were not learnt.
 That emotional reactions tend to manifest in an all or
nothing way
 "therapeutic window" or "window of tolerance" is the
capacity to tolerate and modulate various emotional
states
 Emotion regulation deficit results in little or no
conceptualisation of physical and emotional boundaries
between self and others.
 Techniques for skill building in emotional regulation
boundary development essential in treatment

30. Anxiety response
 http://www.youtube.com/watch?v=jcaHgJarMM
 5 minutes

31. 5.2.Loss of self integrity and self
integration (dissociation)
 Persistent emotional and somatic dysregulation tends to
elicit and intensify dissociative reactions
 The associative processes can become automatic and
involuntary over time and with recurrent use
 Post-traumatic dissociation leads to a typical
amplification of emotions, physical sensations,
knowledge/memory, and associated behavioural impulses
 Structural theory of the dissociation this to splitting of
personal experience into divisions. Often confused with
dissociative identity disorder
 Self perception tends to be profoundly negative and
fragmented
 Negative schemas develop which become dominating
organisational beliefs.

32. Dissociation
 http://www.youtube.com/watch?v=shFWo_ZH
MqM
 8 minutes

33. 5.3..Compromised relationship
with others
 Complex trauma survivors have ample reason to
mistrust other people
 insecure and disorganised attachments make children
and later adults targets for additional victimisation as
their very isolation and neediness with compromised
emotional regulation make them very vulnerable
 Learned patterns of helplessness and expectations of
being treated badly confirms expectations regarding
not fighting back
 Five roles in dysfunctional systems: superhero,
caretaker, clown, rebel, lost child
 Dysfunctional sexual relationships range from sexual
compulsivity to sexual aversion

34. Memory, Trauma & Transference
 http://www.youtube.com/watch?v=tXW1taFj7c
0
 12 minutes

35. 1. Sanderson (2013) Part I: Complex
Trauma. 1. Understanding Trauma and
Complex Trauma. 2. Understanding
Trauma Symptoms.
2. Courtois & Ford (2009) chap 1. Defining
and Understanding Complex Trauma and
Complex Traumatic Stress Disorders,
Julian D. Ford and Christine A. Courtois
3. Courtois & Ford (2013) chapter 1
complex trauma and traumatic stress
reactions. Chapter 2 complex
traumatic stress reactions and disorders
6. READINGS

36. Seminar Homework
 Summarise the effects of complex trauma
developmentally. Describe how the impact of
trauma has different effects depending on the
developmental stage that trauma occurs in the
lifespan of an individual
 Read Courtis & Ford (2013) chap 1 pages 11- 22.