Category Archives: Post-Traumatic Stress Disorder

December 14, 2012 · 2:43 pm

Bessel van der Kolk on curiousity


Watching Bessel van der Kolk’s live CE presentation on trauma and attachment from the comforts of a counseling office (far better than sitting in a hotel room since we can get up and go to the bathroom and make snarky comments from time to time).

He is focusing on neuroscience and the role of the body in trauma and trauma recovery. Here are a couple of tasty quotes:

  • trauma isn’t about what happened but how it lives in you now
  • the most important part of trauma recovery is self-regulation
  • If you can’t be curious about yourself, you can’t get better (speaking of curiosity of one’s body, how it reacts to trauma triggers; the capacity to observe in the here rather than live in the past).

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December 13, 2012 · 9:23 am

Want consultation for your difficult trauma cases?


Just a reminder to those of you who are counselors and therapists out there, starting in January, Dr. Langberg and I will be offering group and individual consultations to mental health professionals seeking help for their domestic and international trauma recovery cases. We will be running a once a month group consultation on Fridays beginning mid January (runs for 6 months) here in the Philadelphia region. If you have any interest in joining the group or having your own private consultation, please check out our website for application and consent forms: http://globaltraumarecovery.org/group-consultation/

Group consultations are a great way to get feedback on a difficult case, learn from peers, as well as easier on your pocketbook.†

 

†consultations can not be considered supervision as we have no authority over your practice.

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October 17, 2012 · 7:03 pm

The biological roots of PTSD…and resilience


Brain structures involved in dealing with fear...

Brain structures involved in dealing with fear and stress. (Photo credit: Wikipedia)

A good friend of mine pointed me to a recent Nature essay that describes the biological markers for PTSD and resilience–and provides some of the answer of why some seem to recover fairly quickly while others continue to struggle. Here’s a couple key quotes:

“Functional magnetic resonance imaging (fMRI), which tracks blood flow in the brain, has revealed that when people who have PTSD are reminded of the trauma, they tend to have an underactive prefrontal cortex and an overactive amygdala, another limbic brain region, which processes fear and emotion…”

“People who experience trauma but do not develop PTSD, on the other hand, show more activity in the prefrontal cortex.”

Of course, we need to understand that we are complex beings with complex histories and current social connections. We don’t only look at neural activity but with increasing understanding, we learn how experiences such as childhood trauma, poor social support influence brain activity.

Some worry that the discussion of biological features of PTSD will lead only to increasing chemical interventions (meds, surgeries, etc.). I do not believe this to be the case given that we are also learning about the ways that current relationships and psychotherapies are altering brain activity.

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September 12, 2012 · 10:47 pm

Dissociation (amnesia) and remembering abuse anew?


How is it that someone could forget a horrific event or experience? What is happening when something new is remembered about a very old event? Is it possible to forget (lose the capacity to recall) for long periods of time but then later remember?

Continuing my series on memory, abuse, and the controversies of recovered memories [you can read my previous posts: here, here, and here], I now want to address the issue of dissociation, amnesia, and remembering abuse. In those previous posts we have looked at how memory can be degraded by intent (conscious denial or unconscious rejection), by other overwhelming stimuli, or by failure to encode. But, since I have not spent much time on the topic of dissociation and repression, I want to say just a few words about these two ideas–in part because they are frequently used but poorly defined.

What is Dissociation? Is Amnesia a better term?

People define dissociation in a variety of ways but most definitions include some disconnection from present reality–sensations of disconnection from self, others, or time–and exists on a continuum. The most mundane forms happen everyday. You are driving from point A to point B but realize you cannot remember what you saw along the way. While we could describe this as a failure to encode data into memory, we could also describe the process, a disconnecting from what is happening in the present. Some dissociation is even beneficial. If you have ever been in pain but then got a distracting phone call, your pain perceptions probably decreased. You were, in effect, dissociating from the present experience of pain.

Now, when we talk about dissociation from a counseling perspective, we are talking about a more significant disconnection from present experiences, one that often seems to happen outside the conscious control of the person (but may be a practiced habit that happens without mindful decision). Dissociative experiences include feeling unreal, disconnected from the body, unable to engage the present, unable to remember salient portions of pesonal identity, or even, rarely, the presentation of alternate personality states that appear to fight for control of the individual.

You can imagine that if you are in the position of a repeated trauma (such as child sexual abuse by a parent figure) and unable to escape it, you might develop ways of dealing with the pain by disconnecting from the present. As a result, you might find that any time you begin to feel unsafe, you naturally disappear in some minor or major way. What happens during that “disappearance” depends on the individual. For some, they are reliving some other experience (I’m no longer present but reliving a painful event in my life). For others, they report being blank–thinking and feeling absolutely nothing. The most telling sign to a therapist is that the client no longer seems to be present in the room (nonreactive or reacting clearly to something other than is going on in the present). Whatever the form of disconnection, most then experience some level of inability to remember portions of the trauma.

Interestingly, there is some evidence that those who dissociate have greater capacity to self-hypnotize. In addition, McNally describes a study (in Remembering Trauma) that followed a person with psychogenic amnesia who had altered brain function when in amnestic states.

Does dissociation lead to forgetting traumatic data?

Can a person dissociate enough to create a persistent amnesia for a traumatic event? There is evidence that those who experience frequent disconnected states have greater difficulty remembering important details of traumatic events. However, many would say that repression is a better conceptual tool to explain such forgetting. But then, repression is not well-defined either (even Freud himself interchanged repression and suppression when talking about decisional vs. unconscious forms of forgetting). Despite the frequent use of repression in common parlance (and without the Freudian baggage) I would suggest that amnesia or motivated forgetting may be better terms, a bit more descriptive and less connected to psychoanalytic theory.

Whatever you call it, some level of forgetting can happen to those experiencing relentless traumas.

  • a young Jewish woman forced into an internment camp has her infant child ripped from her and killed. After the war, a relative asks the woman about the child and the woman responds, “what baby?” Only much later does she remember having a child or how this child died.
  • A young male cannot remember much about his childhood. When asked about his Uncle (only 5 years older than he), he can only remember a vague uncomfortable feeling. His younger brother recounts this uncle would routinely enter their bedroom at night to sodomize both boys. Only after numerous conversations does the older brother begin to remember abuse details, even beyond those supplied to him by his younger brother.

Forgetting then Remembering anew?

In my 23 years of counseling I have never encountered someone who recovered memories of a trauma after completely blocking all memory (I believe it is theoretically possible but extremely rare). I have, however, had a number of clients recall previously long forgotten or vaguely remembered traumas. Often when they recall events with VASTLY new interpretations, so new that it feels like an entirely new memory even as they admit the memory isn’t new to them. Here’s a real example (with details changed to disguise identity),

Alice, a 52-year-old elementary school principal, enters individual therapy at her husband’s insistence to deal with her irritability at home. She admits she has developed a fantasy of leaving her husband for the new (and younger) president of the school board. She discloses that this fantasy began not long after her husband suffered a work-related accident rendering him partially disabled. During the initial intake Alice denied any history of trauma or abuse. As the therapy progressed, it became evident that Alice connected her personal identity to that of being pursued–something that her husband no longer attempted. In addition, her attempts to flirt with the school board president had been ignored. In a moment of frustration, Alice exclaimed, “I’ve always known that men found me very enticing, ever since I developed [breasts] at an early age. I’ve always had to be so careful around men, especially married men. I knew they wanted me and that made me feel dangerous but desirable. Now, who am I if no one wants me?” Alice’s therapist asked her to recount a bit of her early sexual history and without much delay Alice reported her first sexual experience at age 12 with her 35-year-old, married Sunday School teacher. She recalled her teacher hugging and fondling her breasts while telling her about his failing marriage and the need for the two of them to avoid further sexual temptation. At age 16, she reported that she and a 4o-something father of a child she babysat engaged in a 6 month sexual relationship.  Alice’s counselor indicated some surprise at how Alice described both experiences. She asked Alice how she would describe the same interactions between one of her current 6th grade students and a school teacher. Alice immediately flushed with horror. “Why, it would be child abuse!” Once Alice regained her composure, she explored how she had always remembered herself as the protagonist in both experiences. In that session and over the next several weeks, Alice reported a flood of new memories, mostly about things done or said by the two sexually abusing men and now interpreted to be predatory behavior. On several occasions she reported that it felt like she had never had these memories before even though she recounted that she never forgot the sexual encounters. The new interpretations and labels created the experience of recovering long-lost memories–ones that seemed blocked as long as she was responsible for the trysts but freed in light of her victim interpretation.

In this little vignette I want to illustrate that memories of abuse can be forgotten, whether only small portions or large, and remembered anew. Recalled or recovered memories are frequent as individuals gain the freedom to explore events from different vantage points. A therapist does not need to go on an abuse hunt or attempt to conjure up forgotten memories for this to happen. Merely exploring the narrative of a prior difficult experience can be all the priming a client needs to begin to experience “new” remembering.

But here’s where good therapy differs from unethical therapy: how the therapist responds to or pursues memories may be the determining factor when it comes to the development of false memories of past abuse. In the next post we will take up the ethics of memory work and explore therapist habits that may produce false memories of abuse.

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September 7, 2012 · 3:49 pm

What is it like to go to war? Book note


Just began reading Karl Marlantes’ What it is Like to go to War (Atlantic Monthly Press, 2011). If you have loved ones who have served in combat I highly recommend you read this to understand a bit of their experiences. Karl Marlantes is a veteran of the Vietnam War and in this book details the spiritual and psychological impact of killing and combat. While his view of God would vary from most Christians, I think most believers will find his descriptions of war’s destruction on a person very accurate.

Marlantes considers the spiritual nature of war,

Many will argue that there is nothing remotely spiritual in combat. Consider this. Mystical or religious experiences have four common components: constant awareness of one’s own inevitable death, total focus on the present moment, the valuing of other people’s lives above one’s own, and being part of a larger religious community such as the Sangha, ummah, or church. All four of these exist in combat.

Most of us, including me, would prefer to think of a sacred space as some light-filled wondrous place where we can feel good and find a way to shore up our psyches against death. We don’t want to think that something as ugly and brutal as combat could be involved in any way with the spiritual. However, would any practicing Christian say that Calvary Hill was not a sacred space? (p. 7-8)

Just prior to this quote he tells of a harrowing experience where he was in charge of a small band of men defending US interests with no opportunity for backup. Decisions he made led to the deaths of enemies and fellow marines. In a break in the action, a chaplain was flown in bringing, “several bottles of Southern Comfort and some new dirty jokes.” (p. 7) He tells how this “help” wasn’t what he really needed,

I felt responsible for the lives and deaths of my companions. I was struggling with a situation approaching the sacred in it terror and contact with the infinite, and he was trying to numb me to it. I needed help with the existential terror of my own death and responsibility for the death of others, enemies and friends, not Southern Comfort. I needed a spiritual guide. (p. 7)

Consider the book if you live with, love, or work with a veteran of combat.

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August 24, 2012 · 10:10 am

Forgetting Abuse? Some thoughts on motivated forgetting


Could someone really forget something as horrifying as a rape or sexual abuse? How come some people say they never stop reliving a bad experience while others say they have forgotten and cannot remember what happened? How do we best understand these two, seemingly, opposing reactions?

In a previous post I began a short series on the controversies of repressed and recovered memories. In that post I made a few general comments about the nature of memory. It isn’t a particular structure or substance or even stored as one discrete movie but rather is a whole brain process connected to context, mood, and self/other-perception. Memories do not exist outside of narrative or story (unfortunately for those with traumatic histories, these narratives are usually quite jumbled up making it difficult to tell the story well). In general, stories help us remember and remembering tells a story.

In this post I want to address the matter of forgetting abuse. Is it possible? The short answer is yes. Common to forget all of it? No. Common to forget portions? Yes. And even more common to have the experience of a new memory even without ever having forgotten the abuse (this I will address in the next post). It is possible to forget, to no longer have access to one’s own history. But, the bigger question is “how” and “why” rather than “if”.

Complicating factors

Laboratory studies re: memory cannot replicate the experience of sexual abuse or trauma. Thus, we have some rather weak experiments or post hoc, retrospective studies. What these studies point to is that (a) most people don’t forget entire episodes, (b) some forgetting does happen, and (c) some confabulation or memory error also happens (e.g., eye-witness accounts are more frail than we imagine them to be). But even when we get a good study, we find it hard to apply the information to real life. For example, one retrospective study located a number of child abuse victims decades after their ER visit to a hospital. A goodly number denied ever having been abused. While the study could reveal some form of forgetting, we might also be witnessing lying and/or alternative interpretations.

So, we have to admit at the outset we have a large supply of anecdotes of full forgetting, partial forgetting, and no forgetting, and an equally large supply theories and explanations based in part on experience and low power correlational studies. Now, anecdotes and poorly supported theories aren’t reasons to doubt the reality of forgetting trauma (or the reality of false recovered memories). They are, however, good reminders to be wary of applying some general knowledge as complete answer to any specific case. Each case of forgetting trauma needs to be evaluated on its own merits (more on this when I get to a post on clinical/practical interventions).

One more complication. Adults who reveal child sexual abuse experiences rarely have any corroborating witnesses or forensic evidence. They have their memories and that is about it. Families, offenders, and communities have much to lose to admit such abuse could have happened. Thus, outside therapeutic environments, adults have few opportunities to be heard or believed.

By what mechanism do we forget traumatic experiences

“Normal” forgetting happens in a variety of ways. Each of these may be a partial answer as to why someone might forget something very powerful.

  1. Distraction leading to failure to encode. If you are introduced to someone and immediately forget their name (happens to me ALL the time), it is because the information never got encoded (too distracted by preparing to say my own name??). Distractions may come in the form of attending to something very specific or not attending to anything at all. Some victims of abuse report that their memories are fuzzy because they could only focus on the flower pattern on the wall during the actual abuse.
  2. Other memory intrusion. A previous memory may interfere with the clear encoding of a new memory or a new memory may interfere with the recall of an old memory. Victims of extended abuse often report difficulty in remembering when it started and stopped, who was present, etc., especially when  the perpetrator also provided more normal love and attention. The memories (and their competing narratives) make it hard to remember.
  3. Motivated Forgetting. I like but hesitate to use this term. “Motivated” could sound like “willful” or “intentional.” And while some motivated forgetting is intentional, most just happens outside the conscious experience of the one doing the forgetting. If I have a conflict with my wife and I spend the next 5 hours rehearsing her supposed sins against me, I may have difficulty recalling my own misuse of words. I may not consciously say to myself, “I am going to do this so I won’t be able to remember my angry words to her,” but I am engaging in what I call “motivated forgetting.” Obviously, abuse victims would rather NOT remember what happened to them and would rather maintain a positive view of a loved one who did the abuse. Victims may encourage motivated forgetting through several means (again, without conscious decision): repeating a false narrative (“He didn’t mean to do that and I am at fault.”) created by themselves or others, using conscious decision not to think about an event, dissociating during abuse and then dissociating when not being abused, focusing on another possible threat.

Now, these forms of forgetting may not sound like they would lead to the complete forgetting of an event. And that would be true for the vast majority of abuse victims. But, I think we need to remember that it is possible given enough anecdotes of some who recover memories (apart from suggestion by therapist or others) on their own and that do get corroborated by others. Is it common? No. Can mental health professionals cause false memories? Yes (but that is for another post in this series!).

So, why do some remember minute details of trauma? They rehearse them (whether they want to or not). Why do some forget them? Their memories degrade due to forms of memory loss discussed above. Other factors are also likely: natural capacity to dissociate, age/development of victim, culture where abuse took place (e.g., a one-time event in a rather safe environment will have a different impact than repeated experiences where safety has never been present).

In my next post I want to take a few minutes to discuss dissociation, repression, and the experience of re-remembering child abuse later in life.

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August 20, 2012 · 2:33 pm

Of Babies and Bath Water: Navigating the Controversies of Repressed and Recovered Memory


Recently I ran a conference about abuse within the church. In these kinds of venues (this blog and conferences) I am asked about a couple of related problems—the problem of false memories of abuse and the reliability of recovered memories of abuse.

While I intend to address these matters here (and in future blogs), I want to reiterate something that I think gets lost in most conversations about recovered and/or false memories.

Sexual abuse is real. The vast majority of adult reporters of abuse during childhood never forgot the details.

Why say this first? Discussions of rare and extreme cases (i.e., repressed memories, recovered memories, and false memories) tends to create undue suspicion for all adults who choose to reveal their child abuse later in life. It is my experiences that conversations about false memories or recovered memories lead many to assume that a report of extensive or horrific abuse is probably false. So, let us remember that as we take up the matter of fully repressed memories of abuse, we are talking about a very small percentage of people.

But, the issue of repressed and/or recovered memories and the construction of false memories is indeed worthy of a careful review given the strong feelings on both sides of the recovered memory debate. In order to be as careful as possible, I want to consider a few topics that may help us understand the issue. First, I will explore foundational topics (memory, forgetting, repression, and dissociation). Then,  I’ll explore the how trauma is known to create confusion, self-doubt, and “motivated” forgetting. Finally, we’ll take up the practice of counseling victims of sexual abuse and the particular matter of dealing with memory retrieval in counseling. Strap in!

Just in case you NEED to know my opinion at the outset…

I find Partlett and Nurcombe’s 1998 summary of an APA report on the topic to be fairly comprehensive,

The plain point here is the consensus set forth by the Working Group:
1. Controversies regarding adult recollections should not be allowed to obscure the fact that child sexual abuse is a complex and pervasive problem in America that has historically gone unacknowledged.
2. Most people who were sexually abused as children remember all or part of what happened to them.
3. It is possible for memories of abuse that have been forgotten for a long time to be remembered.
4. It is also possible to construct convincing pseudomemories for events that never occurred.
5. There are gaps in our knowledge about the processes that lead to accurate and inaccurate recollections of childhood abuse.[1]

I would add one more point: most people (myself included) in this debate are motivated by strong feelings as well as “facts.” These feelings may be the result of experiences with those who appear to be abused or appear to be falsely accused.

Issue one: Memory and Memory Retrieval

Let me start by stating the obvious: this isn’t a neuropsychology primer on memory and I am not an expert in memory. However, there are a few things on which I think we can agree:

  1. memory is a whole brain biochemical process. While structures like the hippocampus are clearly involved in memory storage, no one structure handles all aspects of memory storage or recall.
  2. memory is multi-faceted. Researchers differentiate between recognition and recall memory, explicit and implicit memory, short-term, long-term, and working memories…and much more.
  3. memory-making is a process.  The formation of memory requires attention, perception, encoding, storage, and retrieval. Thomas Insel calls it a 5 act play. A person moves from perception to long-term encoding to retrieval and finally, expression of memory.
  4. relational and affective context influences memory formation and memory retrieval
  5. the act of recall may change memory,

The concept is simple: memories are not fixed; they are periodically retrieved, and modified each time they are retrieved. This process of strengthening a memory by retrieval is called reconsolidation. One profound implication of this concept is that what you recall is not only a reflection of what you first learned, but also a product of each time you have recalled the original information.

How does this relate to our issue of recall of abuse?

  • memories are both fragile and yet not so. You recall what the house you grew up in looks like, even if you haven’t seen it in 30 years. And yet, your recall may or may not be particularly accurate. You may remember a large house even when it is much smaller to your adult eyes.
  • repetitive recall along with high levels of emotion may solidify memory. Most of us know exactly where we were on the morning of September 11, 2001.  You remember this because you talked about it, played it over in your mind, and because of the powerful biochemical process kicked off when you heard of the first plane crashing into the twin towers.
  • Most child sexual abuse has little corroborating evidence, especially when revealed decades later. This leaves victims by themselves to sort through the narratives they and others tell about their history.  The result? Ample opportunities for both denials of actual abuse as well as false memory.

Return with me to my first point. Most child sexual abuse is never fully forgotten. Some memories may be lost, others distorted, still others intentionally forgotten. Memory, as we have seen here is not a structure but a narrative.[2] In most cases, the story being told has much merit, even if some important details are perceived rightly. Thus memory retrieval during therapy (something that WILL happen whether therapist or client wants it) plays a powerful role in the re-storying work of therapy.

In my next post on this topic, I will make some comments about forgetting, motivated forgetting, dissociation, and repression.

[1] Partlett, DF & Nurcombe, B (1998). Recovered memories of child sexual abuse and liability: Society, science, and the law in comparative study. Psychology, Public Policy, and Law, 4, p. 1273

[2] “Rememberings—whether valid or invalid—are communicated by means of narratives.” Sarbin, TR (1998). The social construction of truth. Journal of Theoretical and Philosophical Psychology, 18, p. 145.

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July 14, 2012 · 3:02 pm

Info for those wanting to serve veterans and their families


I recently watched a 2 hour CE (made free by the APA until 12/31/12) about the common stresses of military personnel and their families. While it didn’t have any information on particular counseling interventions, it did do a decent job giving a brief overview of military lingo and differences between the branches (e.g., why you would NEVER want to refer to a Marine as a soldier). The speaker is from the Deployment Psychology training institute and that site will provide you with ample clinical training continuing education. Some of the on-line trainings are free (unless you want CE credits).

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June 20, 2012 · 5:44 am

Refusing to report abuse and its consequences


As many Americans know, The Jerry Sandusky trial is well underway. Mr. Sandusky is charged with 52 counts of child sex abuse during his era (and following) as assistant football coach at Penn State University. But equally on trial–at least in the media, the court of public opinion, and most likely civil and criminal courts in the near future–are Penn State officials. Chief among those under scrutiny is former PSU president, Graham Spanier. It appears that Mr. Spanier, along with other important University employees knew of accusations and eyewitness accounts of abuse and failed to report the matter.

I have written here about the reasons why we fail to report. We fail to report because we are protecting our own. We fail to report because we worry about backlash, bad press, and we don’t want to get involved in messy situations. But consider now the consequences of not reporting.

1. Protecting the wrong person or entity. allegedly, one email from Spanier states that he wouldn’t report Sandusky for “humane” reasons. Spanier appears to have made the calculation of negative consequences for reporting Sandusky to law enforcement but failed to do the same calculation for probable victims.

2. Destroying trust for future leaders. Ask the general public how they feel about the trustworthiness of leaders within the Catholic church? Ask if they feel that the church’s response (verbal and in legal settings) has helped improve or continue to erode trust? Sadly, future leaders of organizations (those that failed to report child abuse) likely face unmerited suspicion on the basis of the predecessor’s behaviors. Further, such failure to instill trust does not just impact general trust within a community. Victims who were not protected and helped are much less likely to be willing to report abuse that happens in the future.

3. Increasing PTSD symptoms. Many abuse and interpersonal trauma victims report that something traumatized them even more than the original abuse–the failure of those who knew about the events to do something about it. When those you think should protect you do not, you are more likely to experience PTSD.

4. Having no answer for Matthew 25:31-46. You may remember that this passage tells what will happen on the day of judgment. For those who did not do for the “least of these” (care for, protect, serve), tremendous judgment awaits. Strong words.

41 “Then he will say to those on his left, ‘Depart from me, you who are cursed, into the eternal fire prepared for the devil and his angels. 42For I was hungry and you gave me nothing to eat, I was thirsty and you gave me nothing to drink, 43 I was a stranger and you did not invite me in, I needed clothes and you did not clothe me, I was sick and in prison and you did not look after me.’

44 “They also will answer, ‘Lord, when did we see you hungry or thirsty or a stranger or needing clothes or sick or in prison, and did not help you?’

45 “He will reply, ‘Truly I tell you, whatever you did not do for one of the least of these, you did not do for me.’

46 “Then they will go away to eternal punishment, but the righteous to eternal life. ”

Strong words indeed.

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April 24, 2012 · 10:32 pm

Why is some trauma complex? A helpful distinction from Judith Herman


Counselors talk about trauma as if all traumas lead to traumatic reactions. They do not. Some people have significant distress from what might be considered slight traumatic experiences (surely an oxymoron!) while others appear not have any negative or ongoing reactions to very large distressing events.

There’s another problem. We sometimes talk as if all traumatic reactions are the same. This is also not the case. While the symptoms of posttraumatic stress disorder (PTSD) are well-known to many (i.e., intrusive re-experiencing of trauma experiences, emotional numbing and other attempts of avoiding memories or triggers, and hypervigilance), you can find counseling students and practitioners who are less aware of a cousin of PTSD: Complex Trauma.

Defining Complex Trauma

I’m reading Treating complex Traumatic Stress Disorders: An Evidence-Based Guide, edited by Christine Courtois and Julian Ford (Guilford Press, 2009). This is an excellent text if you are interested in exploring the symptoms, neurobiology, and treatment protocols for complex trauma. In the foreword, Judith Herman helps the reader clarify the main difference between regular and complex trauma

These days, when I teach about complex PTSD, I always begin with the social ecology of prolonged and repeated interpersonal trauma. There are two main points to grasp here. The first is that such trauma is always embedded in a social structure that permits the abuse and exploitation of a subordinate group… The second point is that such trauma is always relational. It takes place when the victim is in a state of captivity, under the control and domination of the perpetrator. (xiv, emphases mine).

For trauma to become complex one needs to experience the trauma at the hands of those who are most perceived to control a social unit (family, community, etc.). It needs to be repeated and woven into the fabric of distorted relationships. You can see that prolonged abuses experienced as a child prior to development of an understanding of the world and of the self would have more devastating impact than an unfortunate and distressing event that happens as an adult. If I experience a horrific accident and an unexpected attack by a stranger, I would not, usually, begin to feel unsafe amongst friends and family. I would likely continue to trust them even as I might not trust the larger community. However, if I experience repeated abuse by a teacher, a parent, a relative, a church leader as a young child, I do not have the prior experiences of safety to rely on and thus, I am likely to experience all of the symptoms of PTSD and then some more.

What More Symptoms?

Courtois and Ford give a cursory description of complex trauma on the first page of the book,

…involving traumatic stressors that (1) are repetitive or prolonged; (2) involve direct harm and/or neglect and abandonment by caregivers or ostensibly responsible adults; (3) occur at developmentally vulnerable times in the victim’s life, such as early childhood; and (4) have great potential to compromise severely a child’s development.

Adding to the typical symptoms of PTSD, complex trauma victims also struggle to regulate emotions, impulses, somatic experiences, consciousness, and evidence significant distortions in views of the self and others leading to difficulty forming trust relationships and finding meaning in life and faith.

Those interested in learning more about the current thinking on complex trauma conceptualization and treatment may find this book useful. Others may wish to check out the latest articles at www.traumacenter.org, one of the leading centers in the country focused on the problem of trauma.

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