The difficulties in treatment of Complex PTSD

Survivors of childhood abuse, like other traumatised people, are frequently misdiagnosed and mistreated in the mental health system. Because of the number and complexity of their symptoms, their treatment is often fragmented and incomplete. Because of their characteristic difficulties in close relationships, they are particularly vulnerable to re-victimisation by caregivers. They may become engaged in ongoing, destructive interactions, in which the medical or mental health system replicates the behaviour of the abusive family. Judith Herman in her book Trauma and Recovery from Domestic Abuse to Political Terror notes in Complex PTSD survivors of child abuse often accumulate different diagnoses before the underlying problem of Complex Post-Traumatic Syndrome is recognised. They are likely to receive a diagnosis that carries strong negative connotations. These particularly troublesome diagnoses have often been applied to survivors of childhood abuse: somatisation disorder, borderline personality disorder, and multiple personality disorder (Dissociative Identity Disorder).  Patients, usually women, who receive these diagnoses evoke an unusually intense reaction in caregivers.  Their credibility is often suspect. They are frequently accused of manipulation or malingering. They are often the subject of furious and partisan controversy. These three diagnoses are charged with pejorative meaning. The most notorious are the diagnosis of borderline personality disorder. This term is frequently used with the mental health professions as little more than a sophisticated insult. Herman writes, “as one psychiatrist confess, as a resident, I recalled asking my supervisor how to treat patients with borderline personality disorder, and she answered, sardonically, “You refer them’” Some clinicians have argued that the term “borderline” has become so prejudicial it should be abandoned altogether just as its predecessor term hysteria had to be abandoned according to Herman.

All three disorders common to Complex PTSD are associated with high levels of dissociation particularly for those with Dissociative Identity Disorder (DID) previously known as multiple personalities disorder. People with DID possess staggering dissociative capabilities.  Some of their more bizarre symptoms may be misdiagnosed or mistaken for symptoms of schizophrenia. For example, they may have “passive influence” experiences of being controlled by another personality, or hallucinations of the voices of quarrelling alter personalities. 

When sufferers of Complex PTSD understand that the most troubled features of the disorder are attributable to the sexual and physical abuse/trauma suffered in childhood the disorder becomes more comprehensible in light of the history of their trauma.  More important, survivors become comprehensible to themselves.  When survivors recognise the origins of their psychological difficulties in an abusive childhood environment, they no longer need to attribute them to an inherent defect in the self. Thus the way is opened to the creation of new meaning in experience and a new, unstigmatised identity. Understanding the role of childhood trauma in the development of these severe disorders also informs ever aspect of treatment. The understanding provides the basis for a cooperative therapeutic alliance that normalises and validates the survivor’s emotional reactions to past events according to Judith Herman from her research. She further discusses that a shared understanding of the survivor’s characteristic disturbances of personal relationships and the consequent risk of repeated victimisation offers the best insurance against unwitting enactments of the original trauma in the therapeutic relationship. The core experience and psychological traumas are disempowerment and disconnection from others.  Recovery, therefore, is based on the empowerment of the survivor and the creation of new connections.  Recovery can take place only within the context of relationships, it cannot occur in isolation. The first principle of recovery is the empowerment of the survivor. He/She must be the author and arbiter of their own recovery. Many benevolent and well=intentioned attempts to assist the survivor founder because this fundamental principle of empowerment is not observed. The principle of restoring control to the traumatised person has been widely recognised. Adam Kardiner defines the role of the therapist as that of an assistant to the patient whose goal is the “help the patient complete the job that he is trying to do spontaneously” and so reinstate “the element of renewed control”.

Traumatised people are often reluctant to ask for help of any kind, let psychotherapy. But many people who suffer post-post traumatic disorder do eventually seek help from the mental health system. The therapy relationship is unique.   The therapist becomes the patient’s ally. There is a power imbalance between patient and therapist. The power resides with the therapist and it is the therapist’s responsibility that this power is used to foster the recovery of the patient. The therapist needs to adopt a moral stance Herman asserts whereby she adopts a moral stance expressing a need for resolution of justice for the crime committed against her their patient. The therapist’s role is both intellectual and relational fostering insight and empathic connection.  It is not a pill dispensing roll.

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