Courtois and Ford have demonstrated that they are masters of their subject and are masterful in communicating about the treatment of a very difficult patient population and have contributed a masterpiece in their book, Treatment of Complex Trauma: A Sequenced, Relationship-Based Approach. They present a three-phased approach to treating patients who experience the lifelong consequences of earlier life trauma. Recognizing the deficits in current training, they spell out for the learner the important steps that are necessary in working with these patients. In addition to the emphasis on safety for patients, the authors are diligent in pointing out the pitfalls for the therapist in carrying out the arduous task of helping these patients and the importance of obtaining supervision when needed and attending to their personal needs to be effective as therapists.
The authors clearly set out how they approach their subject in the preface to the book. They point out that specialized information, training, and skills are needed for working therapeutically with traumatized patients. They provide the necessary guidance by presenting two fictionalized case examples and give very specific information about how to deal with each of them throughout the book. Their approach is a relationship-based treatment. The treatment they propose is “eclectic, multitheoretical, integrative, and evidence and consensus based” (p. xv). The eclectic approach includes a blending of psychodynamic, cognitive-behavioral, relational, and systemic roots. There is special attention given to attachment theory. In support of the evidence and consensus base, there is a rich list of references more than 30 pages in length.
The opening chapter begins with Complex Trauma in Childhood by citing of Lenore Terr, a pioneer in uncovering the psychological complexities of traumatized children. The authors point out how Terr distinguishes between single-incident trauma, with its impersonal provocation, versus the type II: the repetitive, complex trauma with “ongoing physical, sexual, and emotional abuse and neglect and other forms of maltreatment in the nuclear or extended family” (p. 11) What sets apart the population that is presented in this book is the highly interpersonal nature of the abuse that traumatizes the individual. As might be expected, the “worst case scenario reported is when the parent or other significant caregiver directly and repeatedly abuses the child” (p. 12). The authors proceed to give examples of complex trauma throughout the life cycle beginning with infancy, toddlerhood, and early childhood and extending into adolescence and adulthood.
Throughout the book, the authors have summarized important principles and findings in tables, which are extremely helpful. For example, the one on Potential Sequelae of Exposure to Complex Trauma lists more than 30 possibilities beginning with extreme mood lability and ending with psychosis and hallucinations. With the plethora of symptoms, they mention how easily these patients can be misdiagnosed with other psychiatric disorders, which can have unintended consequences. To the authors’ credit, they carefully point out to the reader how to deal with each of these behaviors and the complex defense mechanisms should these arise in the course of treatment. Most importantly, the authors mention how “complex trauma prevents, disrupts, or shatters the victim’s ability to develop a sense of self and to trust self and others” (p. 27). The authors guide the reader in the development of trust as an essential ingredient in the treatment of these patients. The authors make a compelling argument for how the symptoms that this population experiences go beyond those of the classic cases of posttraumatic stress disorder (PTSD). Key to understanding these patients are the crippling effects of emotional dysregulation and dissociation.
The authors give details about the rights and the responsibilities of both the therapist and those with this disorder. In table 3, they give an outline of patient rights, from the right to know benefits; to professional expertise; to contractual limitations, appeals, and grievances; and confidentiality, to name a few (pp. 66–67). Excerpts from the ethical codes for national organizations are included from the American Association for Marriage and Family Therapy (pp. 70–74), the American Psychological Association (pp. 76–77), and the National Association of Social Workers (pp. 78–79). Missing are excerpts from the ethical code of the American Psychiatric Association.
In addition to reviewing the 12 goals for PTSD treatment, the authors list the additional goals for the treatment of complex traumatic stress disorders. They highlight “to face, rather than avoid, the trauma memory, to experience the relational safety and attunement in the treatment relationship and to develop and/or restore emotion regulation along with others” (pp. 88–90). In addition to the assessment achieved by the intake interview, the book also includes a list of evidence-informed assessment instruments for these cases (pp. 109–112).
The preparation of the patient for therapy is well thought out and emphasizes safety and stability in the face of a history of trauma that has led to a feeling of being unsafe. Potentially dangerous conditions in the environment such as abusive others, domestic or community violence, abuse, drugs, and weapons are mentioned along with symptoms of suicidality, self-harm, aggression, impulsivity, addiction, and dissociative fugue (p. 123). Psychoeducation for the patient is key in phase 1. “Phase 2 involves therapeutically revisiting troubling memories of past or more recent traumatic events in order to replace experiential avoidance with direct exposure to encourage emotion processing” (p. 189). Essential in this phase is grieving past losses as part of the emotion processing (p. 179). Phase 3 involves the consolidating of therapeutic gains. The authors take care to point out that these phases are not approached in a lockstep fashion. The therapist must be prepared to revisit earlier phases as the needs of the patient dictate.
In addition to the one-on-one therapeutic approach, the authors include a very rich chapter on group, couple, and family therapy. Most helpful are the tables outlining the benefits of group therapy for trauma survivors (pp. 193–194), sample group ground rules (pp. 197–200), and sample screening questions for potential process group membership (pp. 208–209). A vignette points to how individual patients can help each other with the support of the coleaders of the group.
The concluding chapters deal with advanced treatment considerations and relational issues. Foremost is the spelling out of the posttraumatic themes that arise in treatment. These include boundary management and limit setting, wish for a cure through love and nurturance, and overt and covert flashbacks in the transference (pp. 257–259). The concluding chapters highlight the therapeutic relationship and transference and countertransference in complex trauma treatment. The therapist needs to be sensitive to not trying to rescue the patient from the consequences of trauma or to not be turned off by the numbing reactions brought on by dissociation.
This book is not only essential reading for therapists who want to take on the challenge of treating patients with complex trauma but also an excellent source for any professional who engages in psychotherapy. The reader comes away with not only important tools in establishing a meaningful relationship with patients but also a sense of the gratification that results from treating patients and being a partner in their growth and development.
Stephen C. Scheiber, MD
Adjunct Professor of Psychiatry
Northwestern University Feinstein School of
Medicine, Chicago, IL
The author declares no conflict of interest.