Autobiographical writing / Child abuse / Cults / Dissociation / Psychology / Sex trafficking / Torture / Trauma

Treating Complex Trauma: Trauma-Focused Cognitive Behavior Therapy

In an earlier post, War and Torture: Treating Survivors of Ongoing and Repeated Traumas, I mentioned rather briefly that Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) has shown good results in treating survivors of repeated and complex traumas such as war, torture, and childhood sexual abuse. As survivor of complex trauma myself (torture and childhood sexual abuse, as well as ritual and severe physical abuse), I can attest to the veracity of those findings.

Psychodynamic therapies encompass a wide range of theories and practices derived from Freud, his followers, and those who broke away from him. It is focused on expanding the range of the ego. An entity I continue to fail to understand.

Psychodynamic therapies encompass a wide range of theories and practices derived from Freud, his followers, and those who broke away from him. It is focused on expanding the range of the ego. An entity I continue to fail to understand.

For more than 20 years, I have been a psychotherapy services–on and off, but mostly on. Most of it has been unhelpful. I kept going back because I needed help and, darn it, something had to work. But it really didn’t help. Not very much.

And then about 8 years ago, I quit therapy, focused on my job and friendships, found myself an appropriate and supportive intimate partner, began to research some of the mental illness I grew up with, joined online support groups, and started up some do-it-yourself dialectical behavior therapy.

For the first time, I began to get noticeably better in terms of my overall mental health and general sense of well-being. It wasn’t roses by any means, but it wasn’t just running on a hamster wheel anymore. When I did return to therapy two years ago, I used it in a particular, self-directed way. I didn’t just go and see where the conversation took me. And I stopped looking to therapy to provide me some kind of magical insight into myself and focused on telling the story I needed to tell. And I kept getting better.

I’ve been wondering recently why this was. I think I have an answer.

We need a network of people who care about us, even if it's just a little. (Children 6 months after the Haitian earthquake.) Photo credit: IFRCT

We need a network of people who care about us, even if it’s just a little. (Children 6 months after the Haitian earthquake.) Photo credit: IFRCT

Most of the psychotherapy I’ve been engaged in has been psychodynamic in nature. And it is not especially effective with complex trauma. I’m not sure it’s especially effective at all–not more than having a good friend who cares about you and listens to you talk once a week. Or getting a dog. But I can’t really say one way or the other. I haven’t researched it, and I do think different problems have different solutions. So maybe psychodynamic therapy works with some problems. But it doesn’t help you deal with repeatedly being raped, for example, or having lived in a war zone. Not much anyway. And it might take 30 years to notice substantial improvement. And frankly most of us just don’t have that kind of time. Or money.

What works is relatively new on the scene, and that’s why it took so long for me to get help. The science wasn’t there, and I was so conditioned by psychotherapy to believe I needed to confront my difficult feelings that I couldn’t believe there was any other way of working.

I’ll tell you what I did in the end and why it worked. First, I provided myself with psychosocial support. I did not make friends, but I made better acquaintances. I gave myself meaningful work to do that gave my life a sense of meaning. Both the World Health Organization and The International Red Cross and Red Crescent Societies  say that psychosocial support helps communities marshall existing resources to manage difficult situations.

Cognitive Behavioral Therapy assumes that our thoughts, behaviors, and emotions all interact. If we can create change in one, we can often create change in another.

Cognitive Behavioral Therapy assumes that our thoughts, behaviors, and emotions all interact. If we can create change in one, we can often create change in another.

Victoria Follette in her book Cognitive Behavioral Therapies for Trauma mentions that beginning with an initial course of Dialectical Behavior Therapy prior to starting TF-CBT is helpful for some patients with especially intense or complex traumas. It was helpful for me, as I lacked the skills necessary for managing the extremely intense feelings involved in working with my memories of trauma.

This isn’t to say I lacked emotional skills in general. The extremely intense emotions of trauma requires specialized skills. And we don’t learn these just anywhere. They are learned through deliberate effort and practice.

In particular, I incorporated mindfulness and distress tolerance into my emotional management toolbox. Mindfulness helps works against dissociation, and it is the habit of dissociation that makes resolving trauma so difficult. Distress tolerance reduces impulsivity, and it allowed me to dredge up memories strongly associated with suicidal thoughts and urges without endangering my own safety. Those skills gave me a foundation for further work.

Only after that did I start working with memories. I used two strategies from TF-CBT, although there are other strategies with a track-record of effectiveness, and one other variety of CBT that is not specifically designed for treating trauma but was important for helping me address my faulty beliefs from having been raised in a religious cult.

The TF-CBT strategies I used are prolonged exposure therapy (PE) and Cognitive Processing Therapy (CPT). I repeatedly exposed myself to memories of trauma while making a conscious effort to manage the emotions effectively without dissociating (dissociation shuts down the ability to engage in a conscious or deliberate way with the world or with our minds) and I looked at what thoughts and beliefs I had formed during trauma in order to challenge them with more complete information.

The third form of CBT I used was schema therapy, which looks at important beliefs that interfere with functioning. Because I was raised in a cult, and because I was raised by parents who thought in deeply faulty ways, I have inherited a number of faulty beliefs about the world and what it means to be a good person. I don’t believe in these whole-heartedly–I did after all leave the cult world when I was 15–but they linger at the margins of my mind and are also closely tied with trauma memories so that the intensity of the trauma experiences sustains them.

When I returned to work with a therapist, I used my therapist to help me with the PE by telling her about specific, difficult memories. Her role as a sympathetic witness to my experiences has been invaluable, and helps me to re-interpret the world as a place in which I can be cared about and supported. It provides me with direct evidence that my sense of being utterly alone with the trauma is no longer true.

I don’t really recommend a do-it-yourself approach to trauma. It’s much easier and more likely to get you good results if you can undertake it with a trained therapist. But I do recommend that you look for a therapist who can provide you with the appropriate form of therapy.

Just as you would see an oncologist to treat your cancer, you probably want to see a therapist competent in providing effective, trauma-focused therapy to treat your complex trauma. You would not see a family doctor to treat your cancer, or a witch doctor, or a priest, and it won’t help very much to see a psychoanalyst, a generalist, or your local religious leader for your complex trauma. Difficult problems require highly expert solutions.

Further Reading:

Follette, V. and J. Ruzek. (2006). Cognitive Behavioral Therapies for Trauma. New York: Guilford Press. (Available from Google books.)

Resick, P., P. Nishith, P. and M. Griffin. (2003, May). How Well Does Cognitive-Behavioral Therapy Treat Symptoms of  Complex PTSD? An Examination of Child Sexual Abuse Survivors Within A Clinical Trial. CNS Spectrums. Retrieved from:

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9 thoughts on “Treating Complex Trauma: Trauma-Focused Cognitive Behavior Therapy

  1. Pingback: Treating Complex Trauma: Trauma-Focused Cognitive Behavior Therapy | paralysisanalysis's Blog

    • TF-CBT was first introduced for children. I was working through an online pamphlet designed for therapists to use with kids in a TF-CBT series of sessions. It’s out there.

  2. Good for you. I have no idea how you could have survived all that, but thank heaven you did.

    I’ve been watching The Girl With The Dragon Tattoo (and her extraordinary rage) and I have an explosive temper that scares me sometimes. I did not have your trauma, but I faced some really frightening stuff growing up (and with no support through it.) I am glad I survived, but a a price.

    • Thank you for coming over and reading on here. My temper used to scare me too. It’s interesting that it no longer does.

      I’m sorry to hear the price you paid for what you went through.

  3. I am glad you found the help and support that you needed eventually. I’m sorry to hear your experience with therapy initially had not been good. As a therapist myself, I can totally see where the failings of our profession can be, but also I know where the strengths and usefulness can be. Unfortunately, not all therapists are trained the same way, and even when they are, they are not always the most effective, empathic and attuned practitioners. It takes a lot of self-awareness and willingness on the part of the therapist to this sort of work. In any case, as I have been trained in psychodynamic therapies, I have to say, I do see the merits in it, but I also see how, if the therapists don’t get their own personal introspection and insight, then this type of theory can be difficult to use with trauma. Most of all, as I’ve mentioned in my blog post, which you commented on, many models don’t address the cultural component of the client experiences, and it is very much a pitfall for the therapy services. I do hope that as more therapist of ethnic origins become professionals in this field, we can offer better culturally sensitive services to other clients of ethnic origins as well.

    What most research has shown, despite different therapy models, that what really helps clients is the relationship quality between the therapist and client, which a branch of psychodynamic therapy, called relational psychotherapy (or object relations, and some Self Psychology theory) and intersubjectivity psychotherapy emphasize on. It seems like with your last therapist, you had that quality and it was helpful. How I understand mindfulness is that, in some way, it’s like the insight-oriented, consciousness rising aspect of psychodynamic theory (in the field, there is a difference between psychodynamic, especially objection relations theory, and traditional psychoanalytic or Freudian theory….in fact there is a whole history and politics to this, which I won’t go into).

    There is also the feminist theories and family systems theory that emphasize more socio-cultural and systemic influences on human psychology and relationships.

    Now trauma in itself is a whole other thing. What I find is helpful for me, when I’m with my client, is that I enter their world (psychologically and emotionally), and that helps me understand what it really is like to live through that trauma, and also to be still dealing with it years later. Not everyone can or will dare to do that, as it is quite hard to enter someone else’s traumatic world, and bear that pain with another person. But I think that is the most helpful and most useful way of doing therapy. Of course, this can be hard for many therapists to do, as it’s not just one client’s world, but depending on their caseload, it can be up to 20 or more worlds they have to enter in a week. That is quite exhausting after a while. So the therapist really needs to be able to do this, and have professional structures set up to help him or her do it.

    Anyway, long story short, I think you are right, one should find the right therapist for one’s challenges that need to be worked through.

    • Resolving trauma requires particular skills. Psychodynamic therapy does not teach skills. I got better when I developed the skills I needed to have in order to resolve the trauma. I am able to work effectively with my current therapist because I have researched and learned the skills I needed to have outside of her office. If I had done this 20 years ago, I would have been able to use my previous therapists effectively as well. Until recently, the knowledge my therapists needed to have to help me simply wasn’t there. We did not know how to effectively treat complex trauma. We do now.

      Although I agree with you that the quality of the relationship does matter, I disagree with you that that is what the majority of the research indicates. Personally, I have also had good relationships with my therapists over the years. That is simply not enough. I am able to work well with my current therapist because I have researched and learned the skills I need to resolve the trauma outside of her office. She is no more or less effective than any of my previous therapists.

      If all you need is a sympathetic listener, get a dog.

  4. Thank you for writing this.
    I’m starting TF-CBT tomorrow and reading this has made me feel like maybe this time it will be different and maybe this time it will help!
    Thank you.

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