When most of us think of trauma, we think of Post-Traumatic Stress Disorder, the syndrome that frequently results from exposure to extreme stress, such as combat or a natural or man-made disaster. But another form of trauma-related illness can be more far-reaching in its effects.

This type of trauma is associated with a range of behavior disorders including drug and alcohol use, sexual compulsivity, eating disorders, self-harm, depression, anxiety, and panic. It’s called complex trauma, and results from severe, long-term abuse or neglect, particularly in childhood. Experts compare child abuse or neglect to an extended term in a concentration camp – the scars may not be visible, but they are nonetheless real.

While recent exposure traumas are often apparent and readily diagnosable, complex trauma is generally an underlying (and often hidden) factor. Ironically, the trauma that engendered difficulties as an adult may be rooted in barely recalled events from childhood.

Recovery for people with complex trauma is challenging because therapy cannot focus on one presenting problem. Treatment depends on an integrated treatment plan that addresses all the client’s needs, however diverse. Therapists must have special skills and abilities to address the shifting sands of the clinical picture. We can’t always predict which problem will require attention first — or indeed, when opening a door in therapy will introduce a whole new set of emotional needs and issues.

In general, survivors of complex trauma are characterized by the following:

Problems managing emotion and controlling impulses

Trauma clients struggle with intense negative feelings, particularly anger, directed at others or at themselves. Self-destructive and self-harm behaviors are not uncommon. Neither is an extreme need for excitement and risk-taking, often through dangerous or self-defeating relationships. Impulse control may require strengthening in order to break destructive behavior patterns.

Altered consciousness

Most trauma clients suffer from partial or complete amnesia for significant events. Some have periods of dissociation (the mind, under stress, splits memories or thoughts away from normal consciousness, only to surface spontaneously or when triggered by events.) Some experience the phenomenon called depersonalization — a sense of being ‘less than alive’ —  numbed or detached from one’s own emotions.

Distorted self-perception

Trauma can engender a chronic sense of unworthiness as well as an inability to control thoughts, feelings, or environment. Excess guilt and shame are common, as is the persistent belief that ‘no one understands me.’

Distorted relationships

Not surprisingly, trauma victims often experience a pathological reluctance to trust others. They may not feel safe even in a well-controlled environment. Some continuously place themselves in position to be revictimized, as if they are actors in a play written by somebody else. Others fall into a pattern of victimizing others, even those they cherish.

Loss of Meaning

With their foreshortened, pessimistic view of life, many trauma victims struggle with plans or choices. A pervasive sense of hopelessness and helplessness contaminates their ability to effect change, however desirable.

It’s common for such patients to present a history of previous treatment failure. In many cases, that’s because the trauma was never addressed – it was obscured by more recognizable problems, such as chemical dependence, eating disorders, sexual compulsivity, self-injury, depression, or panic disorder.

Treating Complex Trauma

The first step in recovery is stabilization. The client isn’t ready to address the memories associated with trauma until he or she has learned to manage negative emotions and tolerate stress without reverting to old, destructive behaviors. Cognitive approaches such as Dialectical Behavioral Therapy, insight-oriented psychotherapy, and targeted somatic therapies can ‘inoculate’ the client against stress and the mood swings of early recovery.

Once stable, the client uses group and individual work to create a narrative that fills in the inevitable gaps in memory. Client and therapist identify repetitive negative patterns that undermine health and wellness. Internal states can now be connected to actions that once seemed out of control. A new attitude of ‘mindfulness’ takes root.

An array of multi-modal therapies can help identify helpful techniques for the client to maintain awareness of their internal state, and tools to manage problematic situations and responses. Art therapy, somatics, EMDR, equine therapy, massage and body work, and other tools may be useful. New interpersonal connections, and a feeling of trust and intimacy, can be gained in 12 Step and other mutual self-help fellowships.

Stages of change

Complex trauma clients go through predictable stages in their process of change. At first, they are precontemplative, unable to see the role of trauma in their lives. Moving into contemplation, the client opens up to the therapist, but still doubts the value of exploring the past. In the preparation stage, clients proactively plan to address issues in structured group and individual therapy and journaling.

The action stage is a time of insights and moments of clarity. Here, the client begins to accept personal responsibility for recovery – acknowledging the reality of the past, while assuming mastery over his/ her present behavior and emotions. In the maintenance stage, client and therapist work to sustain the gains of therapy through formulation of a viable recovery and continuing care program.

Recovery: Big Room, Many Doors

Many treatments and treatment modalities can benefit the trauma client in the early months of recovery. We can’t always predict in advance who will benefit from which approach. It’s helpful to expose the client to a range of therapies. Surprises await – and we don’t want to close a door prematurely.