Working with Adults with Complex Trauma Histories_Guidelines

The speakers, Chris Courtois and Paul Fruin, discussed professional practice guidelines for treating individuals with complex trauma histories. They emphasized the importance of evidence-based approaches, clinical judgment, and client preferences in developing treatment guidelines. They highlighted the differences between complex trauma and conventional trauma populations and the need for specific guidelines for each. Guidelines aim to provide a framework for clinicians to work within, considering the individual needs of each client. The presentation also touched on the evolving landscape of mental health treatment guidelines and the balance between following medical standards and expanding perspectives in the field. Nice to see you all. Welcome. Nice convivial group, and we hope we will carry that through the presentation today. I'm Chris Courtois, and I'm currently semi-retired and living at the beach in Lewis, Delaware. Ooh, yeah. So I like both parts of that. And this is Paul Fruin, who is an associate professor at Western University. And we're going to be talking today about the professional practice guidelines that we wrote for the treatment of individuals with complex trauma histories. But we're going to begin, and I have to confess, I'm going to be a little bit dry when we start, because I want to explain to you what treatment guidelines are, if you don't have an idea about them. And I've been immersed in the effort. There are seven treatment guidelines that have been developed for the American Psychological Association. I've been involved in six of them. And I'm still here to talk to you about that. I'm still standing, which is, like, amazing. But I do have gray hair now. When I started, I had brown hair. It's quite an endeavor. So before we start, we wanted to let you know that we don't have, we only have these disclosures. We both publish books, and we do conference webinars and seminars and things. And we have presented this before in the last couple of years, because we're really trying to get the word out on treatment guidelines. So the agenda is, again, the sort of boring part of this lecture. We'll be just talking about clinical practice guidelines and what they are. We want to tell you how they developed and how we developed ours, and then tell you about the guideline itself and what we recommend in terms of treating individuals with complex trauma. Now, over lunch, we had lunch partially with Bessel. And Bessel is talking a lot about psychedelic treatment and all the different treatment modalities. And there's a lot of different modalities at this conference. But one of the reasons we think that treatment guidelines are so important is they really put rails up around us, right? And we probably all know people who have gotten, either had transfers that counter transfers, reactions of vicarious trauma, or their own history, or whatever, that's gotten in the way of doing the work. So I'm a big proponent of guidelines so that people can go and look and say, gee, what information do we have that's evidence-based that we can work from, or evidence-supportive? And I'm not a big, I'm not the biggest proponent in the world of evidence-based, so you need to know that to begin with. But also, how do we work with this individual? And how do we adapt? And what do the people who have some authority in this work, either they've done the research or they're clinicians that have been at this for a long time, what do they say? And how can they guide us? And all of us in doing this work really have to have a lot of humility, because there's no one right way to do it, right? You know, every client is different, especially with the complex trauma population. There's lots and lots of clinical dilemmas, and lots of risk that comes up. And then we put that against, for most of us, and I am an old-timer, I admit it, I've been at this for 50 years, but most of us, if not all of us, have had very limited trauma training in our professional training. So what does that mean? We had to learn it by the seat of our pants. Not a good way to learn, right? You make every mistake in the book. And I've made nearly every one, but not all of them. And so treatment guidelines, again, can help us just with a general overview within which we can put the rest of the information. And you can use any technique. You can use psychedelics, but you want to have these specific specifications about the population. Also, one of the treatment guidelines that came up and has been revised this year on a 10-year revision is competencies for treating trauma, which are baseline competencies ranging from a novice and a student all the way up to a very experienced person who would consider themselves an expert. And they differ. And not everybody wants to be an expert. Not everybody wants to do this work. But they should know and should have some general competencies and some knowledge and some attitudes in doing this work. So that's why we're putting emphasis on this. And when we started the complex trauma guidelines, there was very little information about what's different about complex trauma from standard PTSD or conventional PTSD. Now we have a lot of information about that. We also have a diagnosis. So we've incorporated all of that to say there's something different about this population and we need to address that as well. So the background, and this is the dull part, is evidence-based practice has really been promoted, as you know, in recent years. And we're all supposed to be evidence-based even if it doesn't work for somebody. Right? And some of us have been pushed and pulled by insurance companies and managed care to use evidence-based. So it helps you to know what the evidence-based is and what the techniques are. But it doesn't always fit. But in 2006, the American Psychological Association took it upon itself to put together what are the components. And I want you to just pay attention to this because it matches the treatment guidelines. First of all, it's research findings. Okay? So we're looking at the evidence-based because not everything works. And things that we think might work, and I remember hearing Bessel say this maybe 20 years ago, things that we think work, when we study them, maybe they don't. Maybe they don't work as well as we think they do. So the research findings on an ongoing basis. Clinical judgment. Now, I've sat through the evidence-based treatment guideline development where as a clinician I was treated as an idiot. That clinicians don't know anything. We should pay attention to only to the data. So the thing I like about the APA, what we call the triphasic model here, is that it captures clinical judgment and clinical authority. But it's not only that. And finally, the last thing is client preference and context. And this is really important because it has to do with lived experience. It has to do with who the patient or client is and what they prefer. So if they say when you say we have to do PE because it's evidence-based and they say hell no, we need to listen to them and say let's see what else there is in the packet that we have of available treatments. And of course not everybody says that. If you're a big proponent of PE and the VA has been, they've really pushed PE whether a vet wants it or not. So we have to be careful. And one of the components is the client's preference and also who are they contextually, intersectionality-wise. Does it fit for them? And we don't have good data. Does what we do in Western society work in other societies? We're gaining some of that, but we don't have it yet. So the background is the field of medicine has long been developing clinical practice guidelines based on the research. So it's evidence-based. If you've had a major diagnosis in the last number of years, as I have, my doctor pulled up the Mayo data and the Cleveland Clinic data and said look, for what you have, this works and this works. Choose one. That's customized medicine. But I had a preference. It was overwhelming at the time, but I ultimately had a preference. So clinical practice for medicine is relying a lot on this ongoing research phase and also on the preference of the individual. In mental health and behavioral health, we have not had that deep background that medicine has. But in our wisdom or lack of wisdom, I don't know which, we have adopted the Institute of Medicine's standard for developing treatment guidelines based on what the evidence base shows so far. And in mental health, we're now putting together clinical practice guidelines and professional practice guidelines, which I'll mention in a moment. So the current generation is a more emphasis on randomized control trials and methodological stringency. And the question is, is that where we should be going as a mental health or behavioral health field? Should we follow medicine slavishly to come up with treatment guidelines or should we expand the picture? And I'll suggest we should expand the picture. I'm going to be quoting American Psychological Association because it's my main organization, but other organizations have similar kinds of treatment guidelines. So for APA, there are two main types. One is clinical practice guidelines, and those are based on the evidence on randomized control trials only. And professional practice guidelines, by comparison, are looking at the population, looking at the individuals, and talking about what are the characteristics of this population. So one of the things Paul and I did with our guidelines is we made sure that we differentiated what's the difference between complex trauma folks and conventional trauma folks. Yeah, there's a lot of overlap, but there's also significant differences that you should know about if you're going to be treating this population. And so most of the treatment guidelines up until just recently have been a blend of the two, but now that we have a lot more research on trauma, say the last 25 years or so, we now have a lot more data to go by, a lot more treatment guidance. So when we put together a clinical practice guideline, and I was the chair of the APA guideline in 2017, it was supposed to be a two-year commitment. It turned out to be five. And this is the way it goes. And it was the first time that we'd ever used the Institute of Medicine standards, and it's based on a systematic review of the literature. Thank God we didn't need to do that. We didn't have AI back then, but there were organizations that do those for you. Then that's looking at the efficacy of different treatments. They have to be studied by randomized controlled trials so that they're controlled, and there are different search terms that are applied. I mean, this gets us in the weeds, but I wanted to know that it's a very, very detailed kind of thing. And there's a panel of experts that are appointed to an organization, and they take the information that has been gathered and analyzed and put into what's called data tables, and then they make up recommendations for whether we recommend this or don't recommend it, or whether it's neutral. We don't have enough data. And the next slide is just a little bit of a joke, but I just wanted you to see graphically what the process looks like. This is why it took five years, because if you go through this graphic, it's the systematic review process, and then you have to go through what you're studying, how they pull the data, and then through a process of analyzing all of those studies, determining which ones meet a quality criteria. Then they come up with the data set, and all of this just goes on and on and on. And then when you come together, you look at the strength, what's called the strength of the evidence, and make recommendations. So it's a very, even though when you finally make the recommendations, they seem like they're slim, based on what you've gone through, you have gone through a whole lot of data and a whole lot of information. So if any of you are hearing, don't volunteer for this. Right, Paul? Paul and I have gone through it, too. So as part of this process, at APA anyway, we have to put it out for public comment before we can publish it. When we put it out for public comment, we get 800, and we had to answer every single one. And we aggregated them and answered them. But the critiques were really important to look at, that we had too much emphasis on medicine as a standard, okay? And maybe we need an institute of psychology, which has our own methods. And maybe we need an institute of social work, or just a general mental health institute. And so the question is, how do these apply outside of medicine, and do they? Can we offer somebody the same thing, the way they've been doing in medicine? Too much reliance on randomized control trials, and not looking at qualitative or other sources of study that give us a different kind of information. So certainly, you know, if you're relying on RCTs, you're getting the statistical picture, but you're not getting the personal picture. You're getting an overview and an average, and you don't know really if that's going to fit everybody that's in question. Then another important thing was, it looks like the way the data has developed is that cognitive behavioral therapy has really, there's a bias towards it, because that's the kind of studies that are done, are randomized control studies at this point. Most of the work has been done on cognitive behavioral therapy, because it's easier to do. And there's funding for it. And there's academic centers. And when you think about, I'm assuming that most of you are clinicians, if you think about us and our little private practices trying to put this stuff together, forget it. It's really expensive, and our voices can't get in there in a randomized control trial. Another thing that was important that they said is, hey, there's more to PTSD than symptoms. And the main clinical practice guideline that was published in 2017 only looked at the lessening or remission of PTSD symptoms. No other symptoms. And it wasn't the removal or lessening of the PTSD diagnosis. Okay? I mean, if you lessen the symptoms, it's probably lessening of the diagnosis. But many individuals get through CBT training, or treatment rather, and they still have PTSD. And they're still not any better, necessarily. I mean, they may have dropped some symptoms, but they still can be quite symptomatic. We also know there's a high dropout rate, and there can be considerable adverse reactions. Part of the problem with the data right now, and the randomized control data, is they don't often talk about adversities. So, you know, I want to know if I'm going to use something like prolonged exposure, which is really powerful. You know, I want to know what the statistics are for possible leading to decompensation or suicidality or whatever. And another fear is misuse of insurance companies, as I mentioned earlier. I made a joke about it, but it's not funny. How many of us have gone through sort of the, you know, checklist with the managed care person who said, well, I mean, I've had, well, Dr. Courtois, how do you know that this is effective if it's not an evidence-based? And it says here on this check sheet, this is what you're supposed to be doing with this particular patient. Well, how do you know what I'm supposed to be doing with this particular patient? And we also know that one size or one treatment doesn't work for everybody, and we shouldn't assume that. And very importantly, the last point here, is that there was no attention in the clinical practice guidelines for looking at the relationship, the foundation of where we, what we do with these techniques and the relationship that we need to develop. And also, what can we expect in the relationship, especially with people who have been complexly, interpersonally traumatized? So I'm going to pass on this one because I've said it, but you will be able to get copies of these slides, we believe. But I just wanted to give you a list of the seven guidelines that are available from the American Psychological Association. Paul is going to give you the URL. The nice thing about these is APA has published them as little booklets. And they're about 20 pages each, so it's easy, you can download them, you can print them, and you have them in your library. And besides the one we're going to talk to you about today, which is our very favorite, there's a new one on trauma assessment, how to approach somebody to assess them, whether they have a history of trauma or not, and how to assess them if they endorse a history. And there are things to do and not to do. There is also a professional practice guideline that was put together parallel with ours. It's called key considerations for any of you that are doing forensic work. They're paid, in that particular guideline, they paid a lot of attention to the overlap between trauma and forensic involvement. And there's some workshops here on that in this conference. And then finally, I would really, if you don't read anything else, read the guidelines for trauma competencies. It's now a policy of the American Psychological Association and unfortunately it's not followed enough in training programs. But there was a huge conference about ten years ago that involved 60 world-known experts in working with trauma. And we developed a list of what are the main competencies that are needed in addition to, I mean, general competencies, but also specialized competencies. And the list was going over and over and over again and refined. And then just this past year, the whole document was refined again. So it's every year, every ten years or so, these things will be updated. So that's my sort of flat part of the presentation. Paul's going to take it from here and he's going to tell you more about the practice guidelines that we put together for complex trauma. And I will chime in periodically. Paul has the main link for you to identify where to get the guidelines. Thanks, Christine. Thanks. I'm really humbled to have so many people in the room. I know there's some around the corner that I can't even see, but welcome around the corner there. So these are the co-published actually by the APA, which we've credited, but also the ISSTD, which is the International Society for the Study of Trauma and Dissociation. They were published a couple summers ago in 2024. And they were for working with adults with complex trauma histories. And we'll talk just briefly a little bit for the rationale that we really needed these. And Christine has already talked to the effect that we really needed. We felt the professional practice guidelines, partly the rationale was just to respond to the clinical practice guidelines that had recently been published for PTSD, because they were indeed fairly narrow in the end, endorsing only three specific treatments that met the randomized controlled trial criteria and such of the day. And one was that there is a lot of heterogeneity, of course, into the category of what is a traumatic life event. You'll know in the official diagnosis for PTSD from the American Psychiatric Association, as well as internationally, that it's really a physical criterion, right? The person has to be physically harmed, or at least at grave risk of being physically harmed, and not so of a bodily injury and or death. But there are so many different types of events that can create traumatic scenarios for a person that may not necessarily have involved physical threat. And the definition of trauma doesn't pay any attention really to the context surrounding the trauma. So we heard about the case of V earlier today in the ballroom, she so bravely, as I understood it was the first time publicly described what had happened during her childhood with her father. And this kind of sexual trauma, if it occurs in the context of incest, that might be very different than some other kind of scenario. Maybe it's a date rape, maybe it's assault at random in the back of the bar or something. And all of these instances are, of course, horrific and terrible. But the context often plays a significant load as well, in terms of who done it, in terms of how many times it occurred, in terms of the developmental context, how young I was at the first time it occurred. And so attention to the context surrounding the trauma is very important. We've already mentioned that the physical criterion essentially ignores, calls non-traumatic, doesn't meet the definition, different types of psychological trauma, such as emotional abuse and neglect, having parents that never said they loved you, being bullied at school, having no friends, being ostracized for one's weight, for the color of one's skin, for perhaps a cognitive deficit, I maybe have a learning problem and I'm made fun of at school, what a dummy. So these exclusion of these psychological forms, even if there was no, you know, hurt to the arm, bruising or such to the body, these psychological forms of harm often create significant problems for people, of course, and are forms of trauma. And these clinical practice guidelines, by their definition, they had to focus on one diagnosis, which was PTSD at that time, but we also know, of course, that trauma is a risk factor for essentially all psychiatric problems, name any problem, and essentially having the trauma history is a risk factor for having that problem at a higher rate. So we can think of, of course, substance use problems, eating disorders, personality disorders, psychotic disorders, really the list goes on endlessly such that if we've experienced these kinds of events, the greater risk for any disorder. So the focus on PTSD only is a big mistake in being too narrow. Well, I want to add, somewhere we don't have on that list, we, can you put my mic back on? Thank you. Somewhere we don't have on that list that complex trauma is almost exclusively interpersonal, okay, and to make a distinction, the definition, the physical definition is what's known as impersonal, and it's the interpersonal dimension that really makes a big difference as well as all of the other factors that Paul mentioned as we're talking about complex trauma. And in the guidelines, indeed, we do offer a definition, but it's really one that we're going to suggest is a dimensional one. It's how, it's sort of a degree of complexity. It's not a black or a white, it's not a heads or a tails, is it a complex trauma or a non-complex one, but it's the degree, and so there are a number of variables. Christine mentioned the interpersonal was certainly one. So much research to suggest that, let's say, an impersonal event, a random, let's say, car accident, you know, it was a stranger, I never knew the person, they hit me, I may suffer physical injuries as well as psychological injuries, but it is largely an impersonal, it was an accident, but the interpersonal, where it's an intentional element as well, the intentional is one of the other dimensions, the father coming in at night, he is asleep, he's not accidentally walking into the room, right? It's very purposeful, it's intentional and interpersonal. Included in that was the repetition, maybe there's only the one car accident, but the times that dad went into my room late at night, there were many times, right? So it's the repetition of it. And then there is essentially the aspect of the moral and ethical. It's the idea that no one in this room, in their right mind, would say that what dad was doing there was right. We would all agree it was wrong. There is a natural ethics that are transgressed in the case of a complex trauma. And so it's really a moral dimension, an ethical dimension of clear harm and clear wrong in what was done. We also highlight the developmental aspect that this the more it occurred during a younger age and throughout the lifespan, the more complex the load of that trauma. So there are really sort of five degrees, at least of complexity, that we describe there. And the first one, repeated or chronic, the interpersonal relational aspect, the intentional aspect, the moral and ethical, and then the developmental lifespan perspective. So what we came up with in terms of these guidelines, and Christine talked about some of the process, actually in the first draft of the guidelines, they numbered something like 37, I think. And what we did was we shrunk them down through a thematic analysis into 7, and 7 is a magic number in psychology. As you know, the phone number was 7 on purpose because people can actually remember, for the most part, 7 things, right? So we also try and provide this mnemonic, so it's history. And so there are 7 words starting with 7 letters that form this single word, history. We have humanistic principles and values. We have integrative solutions. We have sequential sort of ordering to the therapy and support. We have temporal effects. We have to pay attention to a timeline. We have to be outcome-focused, and it's beyond PTSD, but across various outcomes. We have the relational foundation, the importance, as Christine talked about, of the empirical foundation for the impact of the therapeutic relationship itself. And then the therapy needs to answer the question why. So why is not starting with a why, but it's the word why. And we'll talk about each of these in more detail in the coming minutes. So starting with the humanistic values, and what I want to suggest as well in terms of characterizing trauma is that maybe at the core, this is a dehumanizing experience. If you can think about a lot of traumas, complex traumas, they involve a person being treated as if they're less than human or not human. So we heard about the case of V and the lack of empathy really displayed by the father. It was about his disturbed needs as he walked into the bedroom. She wasn't really there. She was objectified, of course. His attention was just to one part of her body, and the rest of her was essentially not in the room, didn't matter. And so it's a dehumanizing. Other types of complex trauma may involve a person being spat at, pissed on, not fed, not allowed to sleep, removed of their agency, their ability to control the space around them, their peripersonal space that's within the two or three meters around them. They can't shut their door and have it stay shut. Someone's coming in while I'm sleeping. And so, of course, harm has been done, and the first piece of the trauma is just not to add to that load of trauma. And of course, there are cases of therapists misbehaving in various ways, and we can make grave mistakes, of course, and there are penalties for that. But we can also make small mistakes, and of course, we're human too, and humans make mistakes, but we're going to try and be careful. We're going to try not to add to the trauma load. And what we're going to try and do instead is some form of re-humanizing, to provide an experience that's of dignity, is compassionate towards the person, does support the sense of self-worth that they can maybe come to have over time. We heard in the case of V, she really felt nothing of herself. We're trying to do something small just to help her feel something for herself, something good. To foster the agency, and that can be through the choice in the selection of intervention, as we heard Christine mention already. Reinforcing the self-efficacy that our clients can do something good, can make something of themselves. So supporting their resourcefulness, their level of function. And so the humanistic value is really to re-humanize where a dehumanizing experience has occurred. Anything you want to add to that, Christine? I think the H can also stand for humility, that we approach our patients with humility, and when we don't have all the answers, you know, we should not consider ourselves, and even today, you shouldn't consider us as the sage on the stage, you know, that's giving you all the answers. We're giving you some guidance that you can choose to use or not, but the same with the individuals that we work with, that they have choice, and in fact, giving them choice works against the disempowerment that they've experienced, and helps them, I like the re-humanizing idea. Thank you. And Christine promised, the link is at the bottom there, but you don't need that precision, just so you know. If you literally just Google APA working with adults with complex trauma histories, then you're going to get these guidelines. So the first one, the H in history was humanistic, or it could be humility as well. The next referred to the integrative solutions, and really at the base of this, it is that a personalized, client-centered approach is taken. It's flexible, eclectic enough to be tailored to individuals presenting issues and concerns, goals, and preferences, as well as identity intersections and group contexts. And it's suggested that taking such a personalized, client-centered approach could benefit professional practice with individuals with complex trauma histories. So that's a lot of words. What's it really saying? I want to suggest to you that this is a win, I think, for the types of clinicians that would tend to attend this conference. And that's because the integrative approach is more of an open arms approach to what might be helpful than at the other extreme would be the clinical practice guidelines that tell you, you have three choices. You have prolonged exposure, you have cognitive processing therapy, or you have EMDR. That was the full list. It was three. Never mind seven. And so here, whereas the clinical practice guideline is very narrow, you have three options, this is really opening things up to the evidence-informed approach, which is one could make a clear rationale for why something might be helpful, even if it hasn't been demonstrated through the randomized controlled trial just yet. If we've got an evidence-informed, there's lots of research to suggest that such an intervention would be useful, even if the empirical study specifically on that intervention hasn't yet been done. We can take that information to motivate our approach. And it also certainly considers, especially from the trans-diagnostic approach that we're taking, we're not just going PTSD treatment, but persons who have experienced complex trauma history, that's the group that we're looking at. And so that's trans-diagnostic, as we said. That there are many different types of approaches that are more innovative and are just sort of getting studied right now. And so Christine mentioned, and at this conference it's being talked about, that there are the psychedelic therapies, but there are also various other approaches that are being tested. Neurofeedback was also talked about earlier today. I attended one of the talks and I do a lot of research on neurofeedback myself. And so there are these emerging approaches. In my particular line of research, it's neurofeedback or it's other types of technologies. It might be non-invasive brain stimulation. We study that. We use virtual reality to provide sort of immersive experiences that are sort of directly sort of positive in nature for people, allowing them to sort of explore environments and then explore aspects of themselves in sort of a safe context. We know exactly what's going to happen within that VR scenario that we can create. We do different types of dream work and such. And so it is a little more all-embracing. At the same time, I do want to suggest, and I don't want to be misquoted, that this integrative principle does not mean anything goes. Everything's acceptable. Any type of treatment can now be checkmarked as consistent with the guidelines. That's not true. So it does need a strong rationale. And there are many types of treatments that can, of course, be put out there that potentially do actually add to the trauma load, that actually do risk doing some harm for people. And so we really want to avoid that. And have exposed that in some of the earlier days of this conference and others. I shocked Paul this morning. My organization used to run a parallel conference to this one for multiple personality patients. And at the time, therapists were rooming with their clients. They were engaging in all kinds of regressive techniques. And the clients were dragging teddy bears all over the place. And, you know, these were seen as viable therapies. And it turns out they're not. There's nothing to endorse that. So we have to be very careful about that. And my motto is do no more harm. Because, as we said, in the age of the humanizing, these individuals already have been harmed. And they're coming to us to try to get someone to help them to get out of the dilemmas that are in their lives. And the biological kinds of things. Another focus of this conference that is integrative is the embodiment component. And that's been a long time coming. And Bethel's taken it on the chin a few times for endorsing that maybe before there was literature. Maybe before there was research. But we're beginning to gain that research now. And we've been doing the standard trauma research for years. And it's only now catching up. We're beginning to have very complex studies. And there's one that I would like to mention to you that fits in this. And it's a method called finding solid ground. The lead principal investigator is Bethany Brand. Somebody you might know. There's a book. There's a workbook. And they have just completed a randomized controlled trial of an international group of therapists and individuals. And what they found is that if you have a diagnosis that's usually an exclusion criteria, they didn't use it at all. Anybody who met the diagnosis, no matter how severe they were, were included in this study. And then there was a control group against that. And what they found is they had put together a whole program of helping clients find solid ground who were dissociative. And it's literally a metaphor that is part and parcel of how they start. And we're going to talk in a minute about sequence treatment. Finding solid ground is also sequence. It's sequential. But for a lot of these clients, and especially those who are highly dissociated or highly chaotic or addicted or whatever, get into the window of tolerance using those terms. Helping them to get out of the trauma, re-experiencing and dissociation, the far ends of the spectrum, is part of what is healing. And it's a preliminary to the healing process. So I really recommend that very highly because it brings us into a whole new domain. You also mentioned the deep brain reorienting and sensory orientations. That seems to be one of the other clinical frontiers at this point. And Ruth Lanius, who Paul works with, is the lead principal investigator of that method. That's correct. So the deep brain reorientation principle, it really is the sequential support. And this boils down to the following. That sequencing, while flexibly applied, may relate to the relative prioritization of management of present distress and acute stressors versus past trauma history in clinical sessions. So professional services are optimized when they're sequenced into phases or components that emphasize present-centered concerns and stabilization. Versus attending and addressing versus avoiding emotional content of past trauma history. So of course we have the post-traumatic stress disorder, the PTSD. And the P stands for post, of course, which means after. So after the trauma. And the typical interventions that we're going to engage with is some kind of reprocessing of those memories of the prior trauma. But how about if the trauma, of course, is not happening just in the past. It's happening right now. So we have the situation described by V. The trauma happened from age five at least and onward. And she might seek therapy in adulthood to try and understand that better. To try and limit the types of symptoms she's experiencing even now related to those traumas. But then she also described ongoing trauma. And in many ways it was reminiscent of what had happened prior. And so we understand the repetition compulsion. We understand that one trauma is a risk for yet another. But the idea of sequential here is to emphasize safety first. And that's present safety. And so if we're engaged in highly abusive relationships right now, then maybe that needs attention first before going back to some discussion and reprocessing around what happened at age five. And so the sequential is really to deal with the safety first. But also it may require some training. Some, of course, building of the relationship first. But then maybe some coping skills and such in order to use those, transfer those towards the subsequent task. Only when the client's ready for it as to kind of going back there to the past. And those earlier harms. So really first comes first is the safety. But then this principle also does speak to eventually you may have to go back there. You may eventually need to go back to the first time and such. And that really comes up actually in the next principle on the temporal effects. Which I'll just jump into and then ask for your comments, Christine. But the temporal effects is somewhat related. That we want to take the developmental lifespan conceptualization of a person's trauma history. We're not just attending to what happens. We're also therefore attending to when and with whom. The when question, the who question. And we're trying to understand the person's trauma history eventually in a chronological order. So that we maybe can understand the recent events as being a product of the risk factors set up by the earlier events. So developing this comprehensive lifeline or chronology of trauma. Which may start from early infancy. Even of course as we've heard intergenerationally. So before the person's birth there was a context that set up the direct traumas of this life. And we need to really understand all of that. All of that narrative to really understand the eventual impact of what's happened on a person. We haven't mentioned dissociation enough. But one of the things that we now know and if you've tried to do narrative therapy with somebody that brings in attachment also. Who has disorganized attachment history and themselves are very disorganized. Their presentation of themselves and their history is likely to be very disjointed and incoherent. I've sat with clients who are speaking English to me and I have no idea what they're saying. Because they're all over the place. And if any of you have studied disorganized attachment in infants or seen the tapes. You will see that youngsters up to 18 months of age have already learned an attachment style. And if it's disorganized they're running around. There's nothing that's coherent or cohesive because it's hard for them to stay attached to an unstable attachment figure. So that's part of what this is about in terms of the temporal piece is trying to put the pieces together over time. And also working against the dissociation or the avoidance. One of the things we've learned about complex trauma also is these clients are highly avoidant. And they're the ones who are most likely to be dissociative. Dissociation is an avoidance and I also want to put dissociation on a continuum. Not everybody dissociates the same way but we often see dissociative process. And then with the dissociative disorders. Judy Herman's original model and Pierre Jeunet's original model that she built out from is a three phase model. And those of us who have been doing this for a long time have really endorsed that. Because we know the chaos that can ensue with clients that have had these kinds of attachment histories and interpersonal traumatic experiences and how they've been affected. And then all of the secondary aspects in terms of addictions or sex addictions or chaos in their lives or whatever. So it's very important in terms of sequencing for this population. But what I want to say is there's a huge and you should be aware of this. There's a huge conflict within traumatic stress studies about sequencing. Because the folks who endorse the three and I think now it's up to five or six evidence based treatments say that you don't have to wait and stabilize anybody. You just give them this treatment and their symptoms will go away. Well, I did that 50 years ago and I had patients decompensate all over the place. I don't want to see that happen anymore. And so the sequencing is much more conservative. Not everybody's going to need it in the same way to the same depth. But if you've got somebody whose life is in absolute chaos and they're unstable, they're unsafe. You know, it's best to really resolve those issues before and if you're going to get into doing directed trauma work, which is the second phase of treatment. The second phase is where you can use those nice evidence based treatments because they do have efficacy in their application. But we're saying and we're saying back to the critics, you know, a sequence is needed with this population. It's different from the standard PTSD population. Let me add one more thing and then I'll be quiet. We didn't mention that the criteria for the diagnosis of complex PTSD includes the standard criteria for PTSD, but also what's called difficulties in self-organization. And that's the developmental piece, that identification of oneself is usually as bad and worthless. And if you just heard Eve Ensler in her talk, she was eloquent in talking about how bad she felt and who she was. So identity and self-worth are very significant. Emotional regulation, if you haven't been taught anything about emotions or nobody has comforted you or nobody has auto-regulated your emotions, they're likely to be all over the place. And it's not just traumatic stress. If you've been betrayed and betrayed by very close figures, you likely don't trust anybody. And you may seek out the wrong people because that's who you know to interact with. And so relationships are also critical in a critical dimension. So those are the three factors that have been identified along with dissociation in the complex trauma diagnosis. Thanks. And that's a great lead into the next principle, which is indeed in terms of outcomes. What are we tracking here in terms of the successes that we're hoping to have for people? And it may be the PTSD symptom reduction of the re-experiencing of memories and nightmares, the avoidance, the hyper-arousal. The difficulties in self-organization that Christine just talked about, which include the sense of self, the emotions and the interpersonal element. And then also dissociation. Our own model, Dr. Lannis and I, we talk about four dimensions of dissociation at least. This is the altered sense of time. People have the memory but know it's a memory. They know it's in the past. With dissociation, there can be an altered sense of time. So in the case of the flashback, there's a deep level of confusion. It feels like it's happening right now. We have the most negative thoughts about ourselves. I'm bad. I'm dirty. We heard from V that kind of a narrative. But when it's I am, the thoughts are in first person perspective. That is a little different from the dissociative aspect of thought, which places the thoughts into second person. You are dirty. You are gross. It's your fault. It's not like I'm saying to myself, it's my fault. It's like I have other voices in my head saying, it's your fault. You suck. You're ugly. You're gross. And that differentiation in the sense of thought provides a dissociative departure in the cognition. The third dimension is the body. In terms of the embodied experience of trauma. I feel like my body is gross. But we also heard about the disembodiment. I feel like I'm no longer in my body. I don't own it anymore. He took it away from me. It's not mine anymore. That's a clear marker for the dissociative element. The final one is emotion. We can have all kinds of present emotions. I can feel fear. I can feel sadness. I can feel guilt. I can feel shame. I can feel anger. But we can also have the extreme depression of feeling. I can't feel anything. I feel nothing. I feel numb. I'm not there anymore. That would be the dissociative experience. We do talk about four different dimensions of dissociation. That's the 4D model of trauma-related dissociation. This is just to say that the outcomes are trans-diagnostic. It's not just PTSD. We're going to ask about the eating disorders. The binge and purge behavior. We're going to ask about the body dysmorphia. The looking down at myself and thinking things are gross. Or looking weird or strange. Or being outside the body entirely. We can ask about the psychosomatic aspects and expressions. Why is it that I keep having these chronic urinary tract infections? Maybe that makes sense, actually, as I trace that back in terms of the temporal. And I understand where that first happened or when that first happened. Interestingly, it coincided with other kinds of things that were happening around that same time. Now, really, Chris's many books really speak to this especially. The relational foundation. She mentioned earlier in the talk that this is often the ignored part. We robotically just follow this recipe of the evidence-based approach and then people are going to get better. No, it's actually really that we have to be in the room. And the client is going to find it very hard to be in the room. Because every time they've been alone with someone before, something bad has been happening. They were taken advantage of. They were hurt. They were shamed. The lights were off and it was dark. And someone opened the door. So what's happening in therapy, there is a closed door for privacy, but the lights are on. And everything that we're trying to do here, no one's going to be embarrassed about, feel guilty of, because we're being careful. Because we're being careful and humble to ensure that we're not adding to the harm, as we've said. But we're essentially providing a safe space. A place where violence is not going to occur. A place where they're not going to be asked to take off their clothes. A place where they're going to be able to protect their peripersonal space. And we're typically on the other side of maybe a small table in separate chairs. We're not going to ask them to come over and sit on our chair with us. So a safe attachment experience of a certain physical disconnect. We are in each our own respective peripersonal space. But we are sharing in a sort of empathic connection and allowing for, perhaps maybe the first time, a meaningful and safe relationship where trust is established and betrayal is not going to happen. They're not going to ask to be keeping secrets. Well, we're going to have to watch time. Can I make some comments on that? Transference and countertransference, so I am steeped in this stuff. But it's extremely important that we approach our clients with kindness and respect. So our word as part of the relationship and that we're offering them safety. However, they are probably going to be testing us all over the place. And we need to understand that it's not about us. It's about the safest person in the world, and they may still not trust us. And it may take forever. And I had my longest term individual I worked with, at the end of it she said, you know, I trust you 99 percent, but I'll never trust anybody 100 percent. And I thought that was really good. But the relationship can be magic for somebody who's never had that kind of experience. And we're working towards secure attachment. That can happen. The data coming in is that within six months with not everybody and not the most mistrustful, but a stable relationship that is reliable and consistent. Dr. Cluft used to talk about boring his clients into health by his reliability and his constancy and saying the same things. You know, that's a good thing. And it can provide the foundation for security that can then connect with other outside relationships. So another motto is relational healing for relational injury. And again, it speaks to the interpersonal damage that's been done. And also, if you get into feeling really smug, you know, if you find yourself saying, oh, we've really like made it in this relationship, it's really working, be careful. Because that may be the point in time where you become least trustworthy because of the dynamics of interpersonal violence and the betrayal. So you have to be aware of that and be able to ask about it. One of the things we don't have on here is that a lot of this treatment is experiential, asking the individual about how they respond to things, how they think about things. And so if you get hit with, you know, you're the worst therapist in the world and blah, blah, blah, the next question is, how did you arrive at that? Instead of, you know, going up on your haunters and getting defensive and firing them. You know, it has to be a process of exploration over time. Another nice thing, I just reviewed an article and it said that exposure speaks to the emotional experience and that's where trauma starts at the door. Okay, so it's not just trauma exposure, it's relational exposure, who you are, how you present yourself. And that doesn't mean we're perfect. Let me tell you one more funny story. Bethel wrote the introduction to a book on encounter transference and he said that as trauma therapists, we're not perfect. We're not perfect. We're not perfect. And we should not let them think that we're perfect. That we're going to make mistakes. Relational ruptures and there has to be relational repair. Go for it, do the why. So the last principle, and we will complete on time, is the answering of the why question. And really what we're wanting to do in therapy is promote the exploration of this question. So existential questions may come up, the why me. And typically what we're going to have in trauma therapy is that the client has made a sort of a mismeaning or a maladaptive interpretation. The sexual abuse happened because I was special. And I was getting these unrequested meetings in the middle of the night, and I was in the middle of the night, and I was in the middle of the night, and I was in the middle of the night, because I'm the daughter that was the most loved. So that was the interpretation for a long time, and it seems maybe to have allowed her to endure, because that somehow sort of put a positive frame on it for a period of time, but she came to understand that partly through a therapeutic encounter, what if it wasn't because I was special? And this was sort of a revelation. She wasn't being abused because she was special. Doesn't mean she wasn't special, of course. I thought, hmm. Was I being abused because I was special? No, I was being abused because there was a monster in the house. What if I was not special? I'm not sure if that's quite the right question, or quite the right reappraisal. I wanted her to know that she was. She was really special. This monster didn't see it, but what I really liked in her story is she looked at some pictures when she was five, and she said, ah, I was a cute kid, right? I was special. We would have all seen that. In answering the question why, maybe it's because there was a monster, and it shouldn't have ever been that person. There was. But you're still very special, and I'm coming to understand that in a more deep way than just that you were a cute kid, but you're beautiful in so many other ways as well. So just to conclude, if you're practicing within the scope of these particular guidelines, then there are seven. We have the humanistic principles and values. We have the integrative solutions to the presenting problems that the client's showing. We have a sequential approach, one thing before the other. Often it's going to be safety first before the post-traumatic memories are addressed. There's going to be the temporal ordering, the chronology. That's part of the making meaning. We're going to want to measure our outcomes very broadly. It's not just PTSD. It's not just the complex PTSD diagnosis. It's also dissociation. It's also eating. It's also substance use. It's also relationships. Relationships really being the main mechanism that we're offering a person. We're offering a person ourselves really as a means of helping them answer that question of maybe why it happened and where to go from here. We'll conclude with that. Thanks so much for being here to share this time. Just a couple more words about the guideline. There's a lot of text that doesn't get covered in this, so there's some guidelines of what to do and what not to do, some recommended kinds of things to add to this. And then there's a whole series of sub-issues that were not attended to, sort of context and intersectionality and different dimensions of doing this work that we also cover. It's a 29-page document, I think. We will take questions for just a couple of minutes because we just got notice we're going to the book signing. So we will be available there if you want to chat some more. We will have some of our books there. So with that, we thank you for your attention. Wonderful to have you here. Questions? Burning questions? Thank you.