By Christine A. Courtois, PhD, ABPP, Chair, and Paul A. Frewen, PhD, Co-Chair
We are pleased to announce the availability of a new Professional Practice Guideline for Working with Adults with Complex Trauma Histories, published jointly by the American Psychological Association (APA, Division 56, Trauma Psychology) and the International Society for the Study of Trauma and Dissociation (ISSTD) (APA, 2024). The guideline has been under development for a considerable period of time and involved input from an international panel of identified experts in complex trauma. The guideline document is available in its entirety: https://www.apa.org/practice/guidelines/adults-complex-trauma-histories.pdf
At present, there are two different types of professional practice guidelines, per the American Psychological Association: Clinical Practice Guidelines (CPG), and Professional Practice Guidelines (PPG). CPG are based on a systematic review of the Randomized Control Trial (RCT) treatment efficacy research and evaluation of same by a multidisciplinary panel of experts who make graduated recommendations for treatment strategies based on the strength of the evidence.
The APA published its first CPG on the treatment of adults with PTSD in 2017 (APA, 2017) and it is currently under revision. In contrast, PPG such as the new PPG for Working with Adults with Complex Trauma Histories, review available evidence and incorporate clinical consensus descriptions to establish recommendations for clinicians and others regarding treatment approaches, but do not make treatment specific recommendations.
Both types of guidelines can thus be considered complimentary and can be used together. Of note, a PPG for the treatment of adults with PTSD is also in the APA approval pipeline. Once published, it can be usefully co-applied with the current PPG for working with adults with complex trauma histories. Both PPG offer different but compatible information on the treatment of traumatized individuals across the spectrum of severity and impact.
Complex trauma has received increasing professional and public recognition in the past several decades and new research findings indicate that it is likely to be the most common form of trauma. Quoting from the new PPG for Working with Adults with Complex Trauma Histories:
While the current PPG may apply to persons with various trauma histories, the guidelines have been articulated explicitly in reference to persons with more “complex” trauma histories…The complex trauma formulation…expands the definition of trauma from merely physical forms to include other ongoing, progressive trauma and entrapping/coercive interpersonal violence, usually over the course of childhood but occurring at any age and having age- and stage-related developmental and posttraumatic impact. Regrettably, the term “complex trauma” has often been misunderstood within the literature, perhaps owing to authors conceptualizing it to imply a categorical distinction from “simpler” forms of trauma as conventionally defined in the literature, which may have invalidated the experiences of some victims. In contrast, the present guidelines employ a dimensional, continuous model in understanding a person’s trauma history as increasingly “complex,” as a linguistic device, to the degree that they have experienced traumatic life events: (a) repeatedly, (b) in (often significant) interpersonal relationships and (c) under intentional circumstances, (d) that transgressed deeply held moral/ethical principles, and (e) occurred early and across multiple developmental stages. As such, trauma complexity may be best understood on a continuum, from non-interpersonal and accidental (and thereby ethically neutral) circumstances that occurred in a singular instance, to repeated, deliberate, immoral transgressions that occurred within familial, intimate, peer or other close relationships [including in organizations or other systems where they might occur in highly organized forms] from a young age and across the lifespan.
Ford & Courtois (2020) also identified several primary characteristics that differentiate complex trauma from one-time/time-limited and unintentional or impersonal forms of trauma: (1) interpersonal experiences and events that often involve relational betrayal and are perpetrated by trusted others; (2) repetitive, prolonged, pervasive and in some cases, ongoing/never-ending events that are often progressive and escalating in severity; (3) involve direct attack, harm, and/or neglect and abandonment by caregivers or other adults who are responsible for responding to or protecting the victims—this may extend to organizations and cultures that are disbelieving of the victimized individuals and deny the occurrence of the traumatic circumstances and so are unresponsive or that support a safe haven for perpetrators; (4) occurs at developmentally vulnerable times in the victim’s life, often beginning in early life [but can also occur late in life with the highly vulnerable elderly]; (5) has great potential to compromise severely a child’s physical and psychological maturation and development and to undermine or even reverse important developmental attainments at any point in the lifespan.
Acknowledgement of the effects of additional types of traumatic stressors--including those those that are psychological/emotional as well as physical--and that occurred recently and in the past, has opened greater understanding of the role of revictimization and repeated and layered forms of trauma over the entire lifespan as complex and cumulative trauma. Additionally, collective forms of trauma, many of which are embedded in cultural norms and beliefs that are frequently ancestral/historical/transgenerational in nature, have also been identified as complex.
The diagnosis of Complex Posttraumatic Stress Disorder (CPTSD) was included in the International Classification of Disorders-11 of the World Health Organzation (2021), as a “sibling diagnosis” to the recognized symptom criteria of PTSD, such as are similarly defined in the Diagnostic and Statistical Manual-5 TR (American Psychiatric Association, 2022). CPTSD includes additional criteria defined as Difficulties of Self Organization (DSOs) in emotional regulation, identity, and relationship with others and includes attention to dissociation. In addition to these posttraumatic diagnoses, complex trauma is also recognized as being transdiagnostic and, like more conventional forms of trauma, associated with a broad range of psychiatric as well as medical and psychosocial effects.
These often compound the treatment and confound treating professionals until they are recognized as posttraumatic by these same professionals using a “trauma lens” in their assessments and determinations.
The PPG for Working with Adults with Complex Trauma Histories identifies and discusses the following 7 principles of treatment including their rationale and application, using the acronym HISTORY as a mnemonic: 1) Humanistic, attending to and respecting the uniqueness and value of each individual and their history and context; 2) Integrative, applying a variety of treatment strategies according to the unique goals and needs of the individual; 3) Sequential, attending to issues of personal safety, stabilization, and skill building prior to direct exposure to trauma processing; 4) Timeline, giving attention to the lifespan chronology of the individual’s traumatic exposure; 5) Outcomes, establishing and working towards mutually established and defined goals that not only involve symptom reduction but are strength-based and individualized; 6) Relational, providing a trustworthy and responsive relationship, a “safe haven” and “learning laboratory” for the client to develop a more secure self and relationship style; and, 7) whY, reappraising maladaptive meanings and addressing spiritual and existential questions about the trauma and its impact and role in the individual’s life.
These principles all fall within the scope of Trauma-Informed and Trauma-Responsive Care strategies for professionals and organizations. They also incorporate the guidelines on trauma psychology treatment competencies (APA, 2015).
In the final section of the PPG, several additional issues are addressed. These include the lack of attention to trauma in the training curricula of most service professions, including psychology, and the need for specialized training and consultation/supervision to supplement generic clinical training when providing care to complexly traumatized individuals. As treatment strategies are under constant development, clinicians are further encouraged to keep abreast of current research and treatment literature and to engage in continuing education efforts.
Attention to the provider’s overall emotional well-being is also recommended due to the strain and intensity that can accompany working with a highly traumatized population. Clinicians and others should be knowledgeable about vicarious traumatization and treatment traps that are common occurrences when working with adults with complex trauma histories. Such awareness and self-care strategies work against burnout and support sustainability and satisfaction in doing this work.
Of necessity, issues of diversity, equity, and inclusion are to be centered in this treatment as the individual’s contextual issues and intersectionality can impact the motivation for and occurrence of traumatization, its understanding by the victim and its impact (including culture-bound idioms of distress and taboos), and the need for specialized considerations in the treatment. Finally, the parallel development of posttraumatic growth in the therapist and the client has been identified. The client’s resolution of traumatic impact and their personal recovery and life restoration can result in a high degree of professional satisfaction and pride for the clinician working with this population.
We hope that psychologists and other mental health professionals will aspire to be guided by the Humanistic, Integrative, Sequential, Temporal, Outcomes-focused, Relational, and Causal (Why?) principles underline by this new PPG in their work with adults with complex trauma histories.
References
American Psychiatric Association (2022). Diagnostic and Statistical Manual of Mental Disorders 5-TR. (5th Ed.TR).
American Psychological Association. (2017). Clinical practice guideline for the treatment of posttraumatic stress disorder (PTSD) in adults. https://www.apa.org/ ptsd-guideline
American Psychological Association. (2015). Guidelines on trauma competencies for education and training. Retrieved from: http://www.apa.org/ed/resources/trauma-competencies-training.pdf
American Psychological Association (2024). Guidelines for Working with Adults with Complex Trauma Histories. Retrieved from https://www.apa.org/practice/guidelines/adults-complex-trauma-histories.pdf
Ford, J. D., & Courtois, C. A., (Eds.). (2020). Treating complex traumatic stress disorders: Scientific foundations and therapeutic models (Rev. Ed). Guilford Press.
World Health Organization. (2021). International statistical classification of diseases and related health problems (11th ed.). https://icd.who.int/
Comments