Staging Treatment in Complex Trauma

We have all seen a movie in which the protagonist experiences a life-changing epiphany and their course is suddenly changed for the better. Sometimes it’s a moment of disclosure, finally getting it “all out”. And while I think moments of insight and disclosure can be powerful, they represent only one aspect of the therapeutic experience. In fact, a rush to disclosure in therapy can put the client at further risk. Some interventions, including EMDR therapy, get a reputation for providing quick relief. However, especially in the case of post traumatic stress or complex trauma, therapy is paced, steady, and respectful of the client’s boundaries.

Staging treatment is imperative to a successful therapeutic outcome. If therapy is “too slow” the client may feel bored and disengaged. If “too fast” the client may be overwhelmed, flooded with memories and sensations they are not yet able to tolerate. At worst, this can put the client in a crisis.

The therapeutic process can be broken down in 3 stages: (1) Establishing safety and building skills to tolerate affect, (2) trauma processing, and (3) trauma related grief and behavior change.

Establishing Safety and Building Affect Tolerance

According to Stephen Porges, the founder of Polyvagal Theory, “Safety is the intervention”. Building safety is often the longest stage of therapy. Goals include building therapeutic rapport, increasing self awareness, validating the client’s story and experience, and increasing affect (feeling) tolerance. The therapist acts as the compassionate witness to learn the client’s experience and perspective. In addition, we work with the client to build skills to tolerate difficult feeling (or any feeling at all). This may include somatic work to connect to and tolerate sensations in the body—as many trauma survivors often feel disconnected or dissociated. The first stage may also include specific regulation skills or coping skills to tolerate difficult emotions. Because traumatic memories may bring up difficult feelings, we want to make sure our clients can tolerate these feelings—teaching them to swim before throwing them in the pool. Without this first stage, trauma processing may be outside what the client can tolerate, leading to shut down (dissociation, numbing, or compliance) or a fight or flight response (anxiety, panic, or hypervigilance). This first stage often includes psychoeducation to validate the client’s experience and self-compassion work to help the client respond to their suffering in a kind way.

Trauma Processing/Memory Work

The second stage of therapy is often what we think of when we think of therapy. This is where we aim to process traumatic material that continues to impact the client in a negative way. Therapeutic goals for this stage include distinguishing between past and present—as trauma often gets “stuck” in the nervous system—and changing the client’s narrative around the trauma. While we may know cognitively we are safe and the threat has passed, our nervous system may continue to respond as if the threat is still present. We aim to help the nervous system return to a healthier baseline. We then explore the client’s narrative and reframe beliefs around the trauma (i.e. from ‘I am worthless’ to ‘I have value’). This may include working with different parts of the client (adult self, inner child, etc) to extend self-compassion and explore protective mechanisms the client has developed to survive. We will often use EMDR therapy, CBT, parts work (IFS), somatic interventions, as well as other approaches.

Trauma related grief/Behavior Change

Once we have put the past in the past, recognizing we survived and the threat is over, we will likely grieve. Trauma related grief is an often overlooked aspect of therapy. Clients may expect to feel better following trauma processing, and often they will. But once we recognize the experience is over, we will grieve what we lost as a result—perhaps grieving the childhood we never had, the care we did not receive, or the time lost to our fight for survival. This third stage also includes behavior changes, adjustments we make to live healthier lives. This might include setting new boundaries instead of compliance. It might mean practicing self-compassion over harsh self judgement. At this stage of healing we are able to lean into post-traumatic growth in areas of meaning and purpose.

It is not always linear

Therapy, even when there is respect to stages, is not always a linear process. These stages may overlap depending on the course of therapy and what concern is being addressed. Stages may also be influenced by secondary gains, feelings of powerlessness, protective parts of self, addictions, or lack of stability outside of therapy. It is important for therapy to be respectful of your boundaries and specific to your story and goals. Grief, parts work, and self compassion are woven throughout therapy as new work is revealed. This is hard. We are here to help and would be happy to answer any questions you have. You matter.

If you want more information on the treatment of PTS or complex trauma we recommend the following resources:

The Complex Trauma Treatment Manual, Arielle Schwartz

Treating Trauma Related Dissociation, Kathy Steele, Suzzette Boon, and Onno Van Der Hart

The Body Keeps the Score, Bessel Van Der Kolk

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