Posted 27th February 2009
A trauma involves experiencing an extreme event in which you fear you will die and/or experience terror and/or witness or believe that another person will die. These events are thankfully rare in developed economies but can have surprising effects upon people. Traumas can vary from relatively minor events, such as experiencing a road traffic accident involving fear of death but no injury, to major traumatic events, such as the Hillsborough disaster, the recent fires in Australia and military combat.
Why aren't they getting better?
Understanding Complex Trauma Reactions
A trauma involves experiencing an extreme event in which you fear you will die and/or experience terror and/or witness or believe that another person will die. These events are thankfully rare in developed economies but can have surprising effects upon people. Traumas can vary from relatively minor events, such as experiencing a road traffic accident involving fear of death but no injury, to major traumatic events, such as the Hillsborough disaster, the recent fires in Australia and military combat. People vary in their reaction to traumatic events along a continuum from reporting apparently disproportionate responses to minor trauma to being apparently unaffected by major traumatic events. Irrespective of the nature of their response the majority of people will recover from their experience of trauma within three months and/or will respond to psychological treatments focused upon trauma resolution such as trauma focused CBT and EMDR.
However, there is a group of people who do not appear to respond to psychological treatment. These individuals often present as confusing, exasperating and frustrating to treating clinicians and case managers. These individuals do not appear to respond to interventions in a predictable way and often appear to be avoidant of treatment or unable to benefit from treatment. Many of these individuals have difficulty expressing their distress and can become withdrawn and/or hostile to those attempting to engage with them. It is our contention that these individuals are likely to suffer from a complex trauma reaction.
Identifying Complex Trauma
Professionals can recognise potentially complex trauma reactions in their clients by looking out for the following indicators:
If one or more of these factors are evident and the treatment/rehabilitation process has stalled, then an assessment of the potential complexity of the traumatic reaction would be indicated.
Psychological Assessment of Complex Trauma Reaction
The assessment of CTR requires a detailed biopsychosocial assessment. In the majority of cases seen by ourselves one or more of the following factors are found to adversely affect the individual's ability to respond to treatment.
Head Injury (HI): Organic brain damage can have subtle impacts upon an individual's behaviour that are not necessarily apparent to medical staff treating the injured person. It is relatively common for frontal lobe damage to be overlooked and yet an individual may experience significant changes to their personality. These individuals can become impulsive, demotivated or perseverative, all of which could negatively affect their ability to engage in treatment. It is also common for memory problems and some verbal expression difficulties to be overlooked, both of which could make engaging with and benefiting from treatment difficult. In general the impact of head injury can be overcome to some extent, but it needs to be known and factored in to the treatment plan for optimal recovery to be achieved.
Overwhelmed: These individuals are likely to struggle to tolerate the distress of remembering/therapeutically addressing traumatic material. Their response to traumatic material would be likely to reflect one of two causal mechanisms. Firstly, the individual may have experienced a severe index trauma involving multiple traumatic events such as injury to the self and/or witnessing injury to others and/or bereavement/loss.
Secondly, the individual may have experienced previous trauma(s) that have sensitised the individual to the experience of emotions associated with trauma. In both these situations the individual would be likely to need to limit their experience of traumatic material by actively avoiding the trauma. This can be achieved by ensuring all their time is filled with activity (by for example working or developing obsessive coping strategies) or by anaesthetising themselves to the emotional pain of the trauma (by using alcohol, illicit drugs and/or prescription drugs) or by developing behavioural strategies that limit the mind's ability to concentrate on the trauma (for example using eating/not eating or exercise as coping strategies).
Style: These individuals have generally developed coping styles in childhood to manage emotionally damaging or distressing experiences. Many of these individuals had to accommodate to experiences of neglect and/or emotional, physical and sexual abuse. In order to cope with these experiences these individuals limit their involvement with other people and suppress their experience of emotions in order to survive. Unfortunately when this person experiences a trauma they are likely to cope by attempting to suppress traumatic experiences and withdraw from social contact. This would be likely to hinder their ability to engage in treatment/rehabilitation for two reasons. Firstly, they would be likely to resist engagement with professionals and may be seen to be emotionally distant and unapproachable. Secondly, they would be likely to experience complex emotional reactions to trauma with new trauma triggering experiences of previous traumas that have been suppressed, including the childhood traumas that resulted in the development of an avoidant personality style.
These individuals are often emotionally fragile and can be prone to psychological distress and when they experience a traumatic event it is often difficult to separate out the response to the recent traumatic event from their previous experiences of trauma and abuse.
As can be seen from the factors outlined above, individuals with complex trauma reactions will often react in ways that are unusual and apparently destructive to professionals involved. The temptation is to view these individuals either as people who are limiting their ability to recover through their resistance to engage and/or to lengthen treatment/rehabilitation process in the belief that further intervention will enable the person to gain insight and engage more constructively with the treatment/rehabilitation goals. Unfortunately, without interventions specifically targeted at identifying the nature and severity of the complexity these individuals are unlikely to reach an optimal level of recovery. They may as a consequence remain more disabled by their trauma than would be desirable. They may remain socially isolated, fail to engage in work activity and continue to experience disabling post trauma symptoms that limit their daily lives.
In the next edition of CMSUK Newsletter we will outline case examples of the assessment of Complex Trauma Reactions and the practical implications for case management.
Dr Nic Alwin and Dr Gordon J Milson
Applied Psychology Services
43 Knowsley Street
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