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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: http://www.nctsnet.org/nctsn_assets/Articles/40.pdf

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