Welcome to the Spring edition of Blue Knot Review, an electronic journal chronicling recent developments and new perspectives around complex trauma and trauma-informed practice. Power, Threat, Meaning WorkshopsThis full day workshop is for those working in diverse professions across different sectors.
PERTH SYDNEY Revisiting Phased Treatment for Complex Trauma Pam Stavropoulos PhD, Head of Research, Blue Knot Foundation (*Detailed discussion of this topic will appear in the updated Blue Knot Foundation Practice Guidelines for Clinical Treatment of Complex Trauma, to be launched in the coming weeks) Phase-based treatment, which Judith Herman calls `a tripartite model of recovery stages’,[1] has long been endorsed by clinicians of complex, as distinct from standard (`single-incident) PTSD. The stages of the phased model are (1) stabilisation and resource-building, (2) processing of traumatic memory, and (3) integration. The phased model for treatment of complex trauma is endorsed by the ISTSS Expert Consensus Treatment Guidelines for Complex PTSD in Adults.[2] The investigatory research for these guidelines found that 85% of consulted experts reported that they would use a phase-based approach as their first line of treatment.[3] Yet the phased (also called `staged’) approach has also elicited criticism. Critique of the phased approach in general - and of the need for the initial `stabilisation’ phase in particular - has also increased since release of the first Blue Knot Guidelines in 2012. The updated Guidelines of 2019 include a chapter which revisits the benefits of phased treatment in light of this criticism. The case for phased treatment The phased treatment model is based on clinical experience that many sources of complex trauma, including severe childhood trauma, `require an initial (sometimes lengthy) period of developing fundamental skills, including maintaining supportive relationships, developing self-care strategies, coping with symptomatology, improving functioning, and establishing some basic positive self-identity as a prerequisite for active work on memories of traumatic events’.[4] The rationale is that `[b]y the time patients have done the arduous work of the early phase of treatment, they are much more stable.’[5] Thus they are better equipped to address the painful task of processing traumatic memories with reduced risk of retraumatisation. It is important to be aware that the stages of the phased approach are not strictly linear. Rather they are `flexible and recursive, involving a periodic need to return to previous phases… Each phase involves a problem-solving and skills-building approach within the broader context of a relational approach’.[6] Why the challenge? The premise underlying criticism of the phased approach to treatment of complex trauma [7] is straightforward and largely comes from a specific quarter. Official evidence-based `first line’ therapies for treatment of PTSD[8] are relatively short term `intensive trauma-focused’ psychotherapies which do not include a staged approach. Those who oppose the phase-based approach in favour of immediate application of evidence-based treatments `argue that a stabilization phase could delay or restrict access to trauma-focused treatments, thereby preventing immediate benefit from the treatments’.[9] A number of papers which critique the phase-based approach endorse exposure treatment/s and Cognitive Behavioural Therapy (CBT). They contend that complex - as distinct from `simple’ - PTSD is no impediment to immediate and effective application of standard evidence-based treatment approaches. For example, Wagenmans, Van Minnen et al take issue with the `assumption’ that `PTSD patients with a history of childhood sexual abuse benefit less from trauma-focused treatment than those without such a history’.[10] Questioning exposure therapy/ies for complex trauma Exposure therapy exists in various forms and is widely referenced, evidenced, and recommended.[11] It is also applied to a range of psychological disorders as well as to standard PTSD. The foundational premise of exposure therapies is that facing anxiety-inducing stimuli results in decrease of the presenting symptoms and distress. This rationale may seem to be persuasive. But a key point, which is especially applicable for survivors of complex trauma, is the capacity of the person exposed to aversive stimuli to tolerate the feelings it elicits. The distinction between unpleasant and unbearable stimuli is significant here. So, too, is the high risk of dissociation in relation to the latter. While dissociation is a feature of all varieties of trauma,[12] most people with complex trauma `have severe dissociative symptoms’.[13] Following exposure to aversive stimuli, a dissociative response may be elicited which, because less visible than the signs of hyperarousal, may be undetected by the treating clinician. Graded exposure and systematic desensitization (in which anxiety inducing triggers are identified and `graded’ on a hierarchy from most to least arousing) ostensibly mitigate the risk of overwhelm. But as Levine points out, `[t]his type of therapy was originally designed for the treatment of simple phobias, such as the fear of heights, snakes, or insects’.[14] Prolonged exposure therapy is a development of this tradition. Extending and extrapolating from `simple phobias’ to the very different terrain of trauma raises issues rarely addressed by exponents of exposure therapies. As Levine points out, `in aiming to treat PTSD and other diverse traumas, PE took on a very complex and fundamentally different phenomenon than evidenced in simple phobias’.[15] He argues that `the repurposing of a therapy originally designed for simple phobias to treating trauma, which is much more complex, may be a disturbing misapplication of these early methods’.[16] Herman is also explicit that `[w]hat one does not do in early recovery is any form of `exposure’ therapy’.[17] Further grounds for concern about exposure-based therapies for treatment of complex trauma relate to the salience of shame, in that exposure to aversive stimuli may result in rapid and severe decompensation. Frewen and Lanius are not alone in contending that `when a person’s past traumatic experiences are more associated with an experience of shame than they are with anxiety or fear, exposure-based therapies may not be the treatment of choice’.[18] In fact, there are grounds for serious reservation about the applicability of exposure-based treatment, particularly for clients who experience complex trauma, and especially if `they are applied outside of a phase-oriented treatment’.[19] Taking stock While current criticisms have been levelled primarily by advocates of exposure-based therapy, direct and indirect critiques of the phase-based approach also derive from other sources. For example, some new and shorter term psychotherapies combine some of the growing range of available resourcing techniques which can potentially obviate the need for a formal `stabilisation’ phase (and/or other specific stages) as such.[20] This is discussed in chapters 4 and 5 of the updated Guidelines. To critique the critiques of phased treatment is not, therefore, to imply that the staged approach is beyond criticism. Nor is it to contend that problematic issues do not arise in relation to it. An ongoing challenge relates to the point at which a client is `ready’ for Phase 2 work. But it was noted in 2014 that while the effectiveness of `first-line’ treatments for standard PTSD is `well established’, nevertheless `their generalizability to child abuse (CA)-related Complex PTSD is largely unknown’.[21] The conclusion of a recent quantitative review of evidence-based treatment for women with child abuse-related Complex PTSD found that the evidence suggesting the efficacy of predominantly CBT treatments was `limited’.[22] It found `no superior effect size’ for exposure, that affect management `resulted in more favourable recovery and improvement rates and less drop-out, as compared to exposure’, and that CBT treatments `do not suffice to achieve satisfactory end states, especially in Complex PTSD populations’.[23] In light of the extensive and well-documented impacts of complex trauma, the reasons for continuing to err on the side of caution in endorsing a phased treatment approach, as per the ISTSS Expert Consensus Guidelines,[24] remain compelling. It is also ironic that despite criticism of the phased approach, some treatment modalities are now explicitly incorporating phases where this was not previously the case.[25] Based on examination of the critique which has been waged against it, it would seem wise to concur with Rydberg that `[i]f the evidence in support of phase-oriented treatment for PTSD is not entirely conclusive but the research in favour of strictly trauma-focused therapy for the same population is even weaker or inexistent, then there appears to be no solid logical reason to modify current guidelines’.[26] At the same time, evolving and potentially valuable short-term psychotherapies, some of which themselves incorporate variants of phases, and the growing plethora of techniques which can potentially be integrated within the phased model are significant (as discussed in chapter 4 of the updated Guidelines). Clinicians should remain receptive to diverse means by which treatment of complex trauma might be accelerated without sacrificing the safety on which effective therapy depends.
Announcing Blue Knot’s Upcoming Practice Guidelines for Clinical Treatment of Complex TraumaThe previous article was drawn from the upcoming Practice Guidelines for Clinical Treatment of Complex Trauma. Blue Knot will be publishing its new guidelines later in October, to coincide with mental health month and Blue Knot Day. They will be available for purchase and download from the Blue Knot website and further showcased in upcoming editions of Blue Knot Review. The Last Frontier: Practice Guidelines for Treatment of Complex Trauma and Trauma Informed Care and Service Delivery were published by Blue Knot Foundation (then ASCA) in 2012. They elaborated and recommended embedding the core components of effective complex trauma treatment into all psychotherapeutic modalities. This recommendation stands and will remain valid into the future. Prior to the 2012 Practice Guidelines, there were almost no guidelines for the treatment of complex trauma. A notable exception was the pioneering work of Christine Courtois;[27] trauma guidelines were addressed to treating `single incident’ Post-Traumatic Stress Disorder (PTSD). The Practice Guidelines - and the ISTSS Expert Consensus Treatment Guidelines for Complex PTSD in Adults[28] published in the same year - rectified that anomaly. Evolving research and clinical insights, as well as the continuing challenges of treating the multifaceted syndrome described as `complex’ trauma, mean that the original 2012 Blue Knot guidelines require updating. The updated and expanded clinical guidelines include substantial additions to the underpinning research base in a number of areas:
Now more than ever it is important for clinicians to be aware of ways to assist complex trauma treatment. A wealth of relevant and potentially valuable material is now available. But the diversity of this material, and the diversity of forums and formats in which it appears, means that it can be hard for clinicians to navigate. The updated Practice Guidelines provide a means of doing so. As in the first edition, Part 1 presents the actual guidelines, and Part 2 comprises the research chapters – all of them new - on which the guidelines are based. To further assist clinicians who work in the challenging terrain of complex trauma and dissociation, additional sets of guidelines and publications are also being released.[29] These new guidelines reflect the continuing and rapidly evolving terrain of research and clinical treatment in relation to complex trauma and dissociation. Here are a few of the endorsements received ahead of publication:
[1] Judith L. Herman, `Foreword’, in Christine A. Courtois & Julian D. Ford, ed. Treating Complex Traumatic Stress Disorders (The Guilford Press, New York, 2009; 2014, p.xv). News Article The federal government must ensure that a complex trauma strategy is a “pillar” of the nation’s mental health policy moving forward, says Blue Knot Foundation. Speaking ahead of Mental Health Week (6-12 October) and the 10th anniversary of Blue Knot Day (Monday, 28 October), the foundation – which is Australia’s National Centre of Excellence for Complex Trauma – said Australia must respond to the public health crisis of complex trauma, with more than one in four adult Australians experiencing the cumulative impacts of complex trauma. “Over 5 million adults in this country have experiences of complex trauma, which is repeated ongoing interpersonal trauma and abuse, often from childhood, as an adult, or both,” Blue Knot Foundation president Dr Cathy Kezelman said. “Research establishes that it can significantly affect a person’s mental health and wellbeing, with survivors experiencing high rates of anxiety and depression and other mental health issues.” Unless we properly address complex trauma now, Dr Kezelman continued, Australia will be having this same conversation in 10 years’ time and then again in another 10 years. “We need to respond to this growing devastating public mental health issue and its human cost on individuals, families, communities and across generations,” she said. Complex trauma includes child sexual, physical and emotional abuse; neglect; growing up with domestic violence; and growing up with a parent or carer who has their own unresolved trauma, such as with a mental illness or an addiction, the foundation said in a statement. In adulthood, it can occur as a result of domestic and family violence and refugee and war trauma, it added. “Research shows that it is possible to heal from even severe early trauma, and that when parents have worked through their trauma, their children do better. However, to find a path to recovery, people need the right support and to embrace a sense of hope and optimism on their journey to recovery and building resilience,” Dr
Kezelman said. Trainers Required Nationally Blue Knot Foundation is expanding its training arm and is looking for experienced trainers/facilitators to deliver our suite of trauma-informed and clinical packages around the country. This contract position could complement the work of professionals in private practice or who work part time in a trauma service. Blue Knot Professional Development TrainingAs you may be aware, Blue Knot Foundation runs an extensive professional development training process. As part of this process it invests in an ongoing quality assurance process, based on learner, client and trainer feedback. This feedback and current research inform enhancements to existing programs, tailored programs and new offerings. Our quality assurance process in the first half of 2019 has informed updates for a number of the programs which are included in the July-December calendar here and in our in-house program. This includes our updated programs:
We are also excited to offer a new program:
This new one-day professional development training will suit all staff who work with, or manage services for, people who may have experienced historical, collective or intergenerational trauma. This includes service managers, therapists, case workers, counsellors, social workers, psychologists, community, mental health and peer workers, primary care practitioners, policy makers, program managers and other professionals. It has been scheduled for October in Sydney and Melbourne in November but can be delivered in-house as well. You will find more information here In 2018 Blue Knot Foundation delivered more than 330 training days to more than 6,300 attendees. The following is feedback from one participant:
Find comprehensive Training packages and Services information here and a schedule of dates and locations here. Please note that our training can come to you and your organisation anywhere in Australia and can be tailored to suit your specific needs. To find out more please email trainingandservices@blueknot.org.au or call 02 8920 3611 to speak to a member of our training team. Supervision Blue Knot Foundation runs a brokerage service whereby we match the needs of organisations/services seeking group/team based supervision with a suitably skilled supervisor. Supervisors are able to facilitate the following: group clinical and non-clinical supervision, group case consultation and debriefing as well as group based support around vicarious trauma and self-care. Other consultation services are available on request. To find out more, visit https://www.blueknot.org.au/Supervision Organisational Consultancy Blue Knot Foundation’s organisational consultancy supports organisations to design and/or modify their current culture, practices, policies and procedures around the core trauma-informed organising principles of safety, trustworthiness, choice, collaboration and empowerment. To find out more, visit https://www.blueknot.org.au/Consultancy Regional ISSTD Conference, Christchurch NZ The International Society for the Study of Trauma and Dissociation is holding a regional conference from 22nd-24th November 2019 in Christchurch, NZ. The conference will feature pre-conference workshops, plenary and panel sessions, as well as a workshop presented by Pam Stavropoulos PhD, Head of Research and Dr. Cathy Kezelman AM, President, from Blue Knot Foundation. Their presentations will focus on the soon-to-be-released updated Guidelines for Clinical Treatment of Complex Trauma. The Guidelines delineate the conceptual and treatment landscape in 2012 as compared to 2019, review the status of phased treatment for complex trauma in light of some current criticisms and outline emerging treatment approaches and their capacity to address dissociation. This conference offers a unique opportunity to hear from international leaders in the field and acquire new knowledge, skills and tools for your clinical practice with complex trauma clients. Further information about the Conference, including how to register, can be found here. Announcing the National Counselling and Referral Service Supporting people affected by the Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability (Disability Royal Commission) This new service delivered by Blue Knot Foundation and funded by the Federal government opened its doors on 17 October 2019. The Disability Royal Commission The Disability Royal Commission was established on 4 April 2019 and will run for three years. It will look at ways to protect people with disability from experiencing violence, abuse neglect and exploitation. To find out more about the Commission visit the Disability Royal Commission’s website. Counselling support and referrals Blue Knot Foundation has established a specialist service to provide counselling support and referrals for people with disability, their families and carers, and anyone affected by the Disability Royal Commission. This service operates from
Our counsellors can be contacted on 1800 421 468. This is a separate service from the Blue Knot Helpline which provides counselling, support, information and for support around the National Redress Scheme. Who the service is for:
What the service provides:
To find out more go to our website Recommended Reading - This edition we feature a seminal book Treatment of Complex Trauma – a sequenced relationship-based approach by Christine Courtois and Julian Ford. Blue Knot was honoured to receive the following endorsement by Christine Courtois to its upcoming guidelines: As evidenced by these revised and updated guidelines, Australia has taken an international leadership role in developing clinical guidance for the treatment of complex trauma. The authors have consolidated a vast amount of research and clinical literature to arrive at an updated and state-of-the art treatment formulation. Significantly, this document does not stop with those treatments that carry the evidence-based designation but extends beyond them to consider other approaches and strategies for the myriad of developmental aftereffects that make up complex traumatic stress disorders. It places particular emphasis on dissociation as a process by which repeatedly traumatized children and adults protect themselves, a process that needs recognition and attention. Other recommended approaches include an emphasis on the body-mind and the use of treatments long considered complimentary (and alternative) to mainstream talk therapy. In line with recent research findings from the neurosciences and attachment studies, the case is made here to offer treatment that is holistic and oriented towards the client’s identity development, self-management, relationship ability, and other life skills, and an emphasis on life quality rather than only on the trauma. This model emphasizes the necessity for individualized assessment and treatment formulation, with interventions offered sequentially across three main phases. I repeat what I wrote in my endorsement of the earlier guideline: “This document is a singular and pioneering achievement in its depth and scope…Bravo to all involved in its development! Christine A. Courtois, PhD, ABPP This insightful guide provides a pragmatic roadmap for treating adult survivors of complex psychological trauma. Christine Courtois and Julian Ford present their effective, flexible research-based approach for helping clients move through three clearly defined phases of posttraumatic recovery. Two detailed case examples run throughout the book, illustrating how to plan and implement strengths-based interventions that use a secure therapeutic alliance as a catalyst for change. The book also explores the roadblocks which inevitably occur within therapy including challenges to the therapeutic relationship, and how to manage them. Essential topics include managing crises, treating severe affect dysregulation and dissociation, and therapist self-care. The companion website www.guilford.com/p/courtois2 offers downloadable reflection questions for clinicians and extensive listings of professional and self-help resources. A new preface in the paperback and e-book editions addresses key scientific advances.
Christine A. Courtois, PhD, ABPP, a board-certified counseling psychologist, is retired from private practice in Washington, DC, and is a consultant/trainer on topics on trauma
psychology and treatment. She cofounded and then served for 16 years as Clinical and Training Director of The CENTER: Posttraumatic Disorders Program, in Washington, DC. Dr. Courtois was chair of the Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder in Adults for the American Psychological Association (APA), released in 2017, and for guidelines on the treatment of complex trauma for several professional organizations. She has published a number of books (four of them coedited or coauthored with Julian Ford) and numerous book chapters and articles on trauma-related topics. Dr. Courtois is past president of APA Division 56 (Trauma Psychology) and past founding Associate Editor of the Division's journal, Psychological Trauma: Theory, Research, Practice, and Policy. She served two terms on the Board of Directors of the International Society for
Traumatic Stress Studies (ISTSS). She has received the Award for Distinguished Contributions to Independent Practice from the APA, the Sarah Haley Award for Clinical Excellence from ISTSS, and, most recently, the Award for Distinguished Service and Contributions to the Profession of Psychology from the American Board of Professional Psychology.
Blue Knot Review is an electronic journal chronicling recent developments and new perspectives around complex trauma and trauma-informed practice. Contact newsletter@blueknot.org.au for feedback or to contribute. Click here to subscribe or forward this email to anyone who may be interested The Blue Knot Helpline has established a referral database of mental health practitioners, doctors, |