UnderstandingComplexTrauma,ComplexReactions,andTreatmentApproaches

ChristineA.Courtois,PhD
Psychologist,IndependentPractice
ChristineA.Courtois,PhD&Associates,PLC,Washington,DC
www.drchriscourtois.com
email:CACourtoisPhD@aol.com
Thisarticleiswrittenprimarilyforbeginningtherapistsandpractitioners.Itprovidesan
overviewofwhatconstitutescomplextraumatization,commoninitialandlongterm
responsesandsymptomsandtheirdiagnosticconceptualizationascomplexPTSDor
DESNOS(DisorderofExtremeStressNotOtherwiseSpecified).Italsoprovidesan
overviewoftreatmentsequencingandstages.
Whatiscomplextraumaandwhatmakesitdifferentfromotherformsofpsychological
trauma?Complextraumagenerallyreferstotraumaticstressorsthatareinterpersonal,
thatis,theyarepremeditated,planned,andcausedbyotherhumans,suchasviolating
and/orexploitationofanotherperson.
Ingeneral,interpersonaltraumatizationcausesmoreseverereactioninthevictimthan
doestraumatizationthatisimpersonal,theresultofarandomeventoran"actofGod,"
suchasadisaster(i.e.,anaturaldisastersuchasahurricaneortsunami,atechnological
disaster)oranaccident(i.e.,amotorvehicleorothertransportationaccident,abuilding
collapse)duetoitsdeliberateversusaccidentalcausation.Athirdtypeoftrauma,a
crossoverbetweenthetwo,referstoaccidentsordisastersthathaveahumancause
(i.e.,technologicaldisastersuchastherecentGulfoilleakoratransportationor
buildingaccidentcausedbyhumanerror,neglect,ormalfeasance).Traumaticstressors
ofthistypehavebeenfoundtocausereactionsthataremoreseverethanthosethat
areimpersonalandlessseverethanthosethatarestrictlyinterpersonal.
Whileinterpersonalviolencecanbeaonetimeoccurrencethattakesplacewithout
warningand"outoftheblue"usuallyperpetratedbyastranger(i.e.,arobbery,a
physicalassault,arape),whenitoccurswithinthefamilybetweenfamilymembersorin
otherclosedcontextsthatinvolvesignificantrolesandrelationships,itisusually
repeatedandcanbecomechronicovertime.Childabuseofalltypes(physical,sexual,
emotional,andneglect)withinthefamilyisthemostcommonformofchronic
interpersonalvictimization.Suchabuseisoftenfoundedonproblematicandinsecure
attachmentrelationships(betweenparentandchildorotherswhohaveprimary
caretakingresponsibilities).Parentsandothercaregiverswhoabuseexploitachilds
physicalandemotionalimmaturityanddependentstatustomeettheirownneedsordo
soinresponsetotheirowninadequaciesordistress,quiteoftentheirownhistoryof
unresolvedtraumaand/orloss.
Ratherthancreatingconditionsofprotectionandsecuritywithintherelationship,abuse
byprimaryattachmentfiguresinsteadbecomesthecauseofgreatdistressandcreates
conditionsofgrossinsecurityandinstabilityforthechildincludingmisgivingsaboutthe
trustworthinessofothers.Whenitoccurswithamemberofthefamilyorsomeoneelse
incloseproximityandinanongoingrelationshipwiththechild(i.e.,aclergymember,a
teacher,acoach,andatherapist),itoftenoccursrepeatedlyand,inmanycases,
becomeschronicandescalatesovertime.Thevictimizationmighttakeplaceona
routinebasisoritmighthappenoccasionallyorintermittently.Whateverthecase,the
victimusuallydoesnothaveadequatetimetoregainemotionalequilibriumbetween
occurrencesandisleftwiththeknowledgethatitcanhappenagainatanytime.This
awareness,inturn,leadstostatesofongoingvigilance,anticipation,andanxiety.Rather
thanhavingasecureandrelativelycarefreechildhood,abusedchildrenareworriedand
hypervigilant.Thepsychologicalenergythatwouldnormallygotolearningand
developmentinsteadgoestocopingandsurvival.
Childabuse,occurringinthecontextofessentialrelationships,involvessignificant
betrayaloftheresponsibilitiesofthoserelationships.Inaddition,itisoftenprivateand
thechildiscautionedorthreatenedtonotdiscloseitsoccurrence.Unfortunately,when
suchabuseisobservedorachilddoesdisclose,adequateandhelpfulresponseislacking,
resultinginanotherbetrayalandanothertypeoftraumathathasbeenlabeled
secondarytraumatizationorinstitutionaltrauma.Itisfortheseadditionalreasonsthat
complextraumatizationisoftencompoundedandcumulativeandbecomesa
foundationonwhichothertraumaticexperiencestragicallyoccuroverthecourseofthe
individualslifespan.Researchstudieshaverepeatedlyfoundthatwhenachildis
abusedearlyinlife,especiallysexually,itrendershim/hermuchmorevulnerableto
additionalvictimization.Suchchildvictimscanbecomecaughtinanongoingcycleof
violenceandretraumatizationovertheirlifecourse,especiallyiftheoriginalabuse
continuestogounacknowledgedandtheaftereffectsunrecognizedanduntreated.
Cumulativeadversitiesfacedbymanypersons,communities,ethnocultural,religious,
political,andsexualminoritygroups,andsocietiesaroundtheglobecanalsoconstitute
formsofcomplextrauma.Someoccuroverthelifecoursebeginninginchildhoodand
havesomeofthesamedevelopmentalimpactsdescribedabove.Others,occurringlater
inlife,areoftentraumaticorpotentiallytraumaticandcanworsentheimpactofearly
lifecomplextraumaandcausethedevelopmentofcomplextraumaticstressreactions.
Theseadversitiescanincludebutarenotlimitedto:
o Povertyandongoingeconomicchallengeandlackofessentialsorother
resources
o Communityviolenceandtheinabilitytoescape/relocate
o Homelessness
o Disenfranchisedethnoracial,religious,and/orsexualminoritystatusand
repercussions
o Incarcerationandresidentialplacementandongoingthreatandassault
o Ongoingsexualandphysicalrevictimizationandretraumatizationinthe
familyorothercontexts,includingprostitutionandsexualslavery
o Humanrightsviolationsincludingpoliticalrepression,genocide/"ethnic
cleansing,"andtorture
o Displacement,refugeestatus,andrelocation
o Warandcombatinvolvementorexposure
o Developmental,intellectual,physicalhealth,mentalhealth/psychiatric,
andagerelatedlimitations,impairments,andchallenges
o Exposuretodeath,dying,andthegrotesqueinemergencyresponsework
Tosummarize:complextraumaticeventsandexperiencescanbedefinedasstressors
thatare:
(1)repetitive,prolonged,orcumulative(2)mostofteninterpersonal,involvingdirect
harm,exploitation,andmaltreatmentincludingneglect/abandonment/antipathyby
primarycaregiversorotherostensiblyresponsibleadults,and(3)oftenoccurat
developmentallyvulnerabletimesinthevictimslife,especiallyinearlychildhoodor
adolescence,butcanalsooccurlaterinlifeandinconditionsofvulnerabilityassociated
withdisability/disempowerment/dependency/age/infirmity,andsoon.
Suchcomplexstressorsareoftenextremeduetotheirnatureandtiming:someare
actuallylifethreateningduetothedegreeofviolence,physicalviolation,and
deprivationinvolved,whilemostthreatentheindividualsemotionalmentalhealthand
physicalwellbeingduetothedegreeofpersonalinvalidation,disregard,deprivation,
activeantipathy,andcoercioninvolved.Manyoftheseexperiencesarechronicrather
thanonetimeortimelimitedandtheycanprogressinseverityovertimeas
perpetratorsbecomeincreasinglycompulsiveoremboldened/entitledintheirdemands,
astraumabondsdevelopbetweenperpetratorandvictim/captive,and/orastheir
originaleffectsbecomecumulativeandcompoundedandthevictimsincreasingly
debilitated,despondent,orinastateofadaptation,accommodation,anddissociation.
Becausesuchadversitiesoccurinthecontextofrelationshipsandareperpetratedby
otherhumanbeings,theyinvolveinterpersonalbetrayalandcreatedifficultieswith
personalidentityandrelationshipswithothers.
ComplexReactions
Itisnowunderstoodthatongoingabuseoradversityoveranydevelopmentalepochbut
especiallyoverthecourseofchildhoodcanhavemajorimpactontheindividuals
developmentinavarietyofwaysandinvolvealllifedomains.Infact,recentstudies
havedocumentedthatabuseandothertraumaresultinchangesinthechilds
neurophysiologicaldevelopmentthat,inturn,resultinchangesinlearningpatterns,
behavior,beliefsandcognitions,identitydevelopment,selfworth,andrelationswith
others,tonamethemostcommon.Althoughsomeindividualswhoweretraumatizedas
childrenmanagetoescaperelativelyunscathedatthetimeorlater(oftendueto
personalresilienceortohavinghadarestorativeandsecureattachmentrelationship
withaprimarycaregiverthatcounteredtheabuseeffects),themajoritydevelopeda
hostofaftereffects,someofwhichwereposttraumaticandmetcriteriafor
PosttraumaticStressDisorder(PTSD).ButthePTSDdiagnosisascurrentlydefinedinthe
DiagnosticandStatisticalManualIVTRoftheAmericanPsychiatricAssociation
(AmericanPsychiatricAssociation,2000)(thementalhealth"Bible"thattherapistsand
othersusetomakediagnoses)doesnotaccountformanyoftheaftereffectsseenin
childrenandlaterinadultsabusedaschildren,andisnot,infact,adiagnosisfor
childhoodPTSD.Asofyet,nosuchdiagnosishasbeenincludedintheDSM,althougha
proposalforaDevelopmentalTraumaDisorder(DTD)hasbeenproposedsubmittedfor
itsinclusioninthenextedition(vanderKolk,2005)
Inrecognitionofthisomissionandthemisfitencounteredinapplyingmanyofthe
complextraumareactionstothecriteriaof"standard"PTSD,areviewofthemost
commonaftereffectsofchronicchildhoodabuseresultedintheirorganizationinto
sevencriteriasetsthatwereincludedinanewdiagnosticconceptualizationlabeled
ComplexPTSDorDESNOS(DisordersofExtremeStressNotOtherwiseSpecified)
(Herman,1992a&b).ComplexPTSDwassuggestedasameansoforganizingand
understandingtheoftenperplexingarrayofaftereffectsthathadbeenidentifiedinto
onecomprehensiveandoverarchingdiagnosis.Moreover,thediagnosiswasawayto
destigmatizeaftereffectsandsymptomsbyacknowledgingtheiroriginasoutsidethe
individualandnotduetothecharacter(orcharacterdefect)oftheindividual.
Unfortunately,thesenegativepointsofviewhavebeenheldbymanymentalhealth
practitionersovertheyearsthatimpactedtheircompassionforandtreatmentof
traumatizedindividuals.Sadly,ComplexPTSDwasnotincludedasafreestandingmental
healthdiagnosisintheDSMIVandwasinsteadconsideredasanassociatedfeature
formofPTSD,althoughthismightchangeinthefuturerevisionswithadditional
researchfindings.Inthemeantime,manytherapistswhotreatchildrenandadultswith
complextraumahistoriesandcomplextraumareactionsusethisconceptualization
becauseitmatcheswhattheyseeintheirclientspresentationsandhelpsthemto
explainandorganizethesymptomsandtofurtherorganizetheirtreatment.Infact,
ComplexPTSD/DESNOSwasimmediatelyacceptedandusedbyawidevarietyof
clinicianstreatingpatientswithcomplextraumahistoriesbecauseithadfacevalidityin
thatitmatchedthevariedpresentationsmadebytheirclientsandwasamore
parsimoniousandlessstigmatizingwaytounderstandanddiagnosethesymptom
constellationtheypresented.
The"traditional"or"classicalstandard"criteriathatmakeuptheoriginaldiagnosisof
PTSDintheDSMIVIIITR(AmericanPsychiatricAssociation,1980)werederivedfromthe
studyofwartraumaandadultsoldiersandincluded:(1)intrusivereexperiencingof
traumaticmemories,(2)emotionalnumbingandavoidanceofremindersofthetrauma,
includingmemoryloss,and(3)hyperarousal,inadditiontovariousassociatedfeatures
suchasdepressionandanxietyandothercomorbidities.Complextraumaticstress
disordersroutinelyincludeacombinationofadditionalDSMIVTRAxisIandAxisII
(developmental/personality)disordersandsymptoms,AxisIIIphysicalhealthproblems,
andsevereAxisVpsychosocialimpairments.Duetothecomplextraumaticantecedents
(inthedistantpastaswellasinthepresent)andtheresultantarrayoftraumaticstress
symptomsandotherimpairments,complextraumaticstressdisorderstendtobe
difficulttodiagnoseaccuratelyandtreateffectively.Itwouldbeusefultohavea
diagnosticconceptualizationthatisencompassingtounderstandandorganizethe
variousaftereffects.
Thesevencategoriesofadditionalaftereffectsincludethefollowing:
1.Alterationsintheregulationofaffectiveimpulses,includingdifficultywithmodulation
ofangerandoftendenciestowardsselfdestructivenesss.Thiscategoryhascometo
includeallmethodsusedforemotionalregulationandselfsoothing,eventhosethatare
paradoxicalsuchasaddictionsandselfharmingbehaviors;
2.Alterationsinattentionandconsciousnessleadingtoamnesiasanddissociative
episodesanddepersonalization.Thiscategoryincludesemphasisondissociative
responsesdifferentthanthosefoundintheDSMcriteriaforPTSD.Itsinclusioninthe
CPTSDconceptualizationincorporatesfindingsthatdissociationtendstoberelatedto
prolongedandsevereinterpersonalabuseoccurringduringchildhoodand,secondarily,
thatchildrenaremorepronetodissociationthanareadults;
3.Alterationsinselfperception,predominantlynegativeandinvolvingachronicsenseof
guiltandresponsibility,andongoingfeelingsofintenseshame.Chronicallyabused
individuals(especiallychildren)incorporateabusemessagesandposttraumatic
responsesintotheirdevelopingsenseofselfandselfworth;
4.Alterationsinperceptionoftheperpetrator,includingincorporationofhisorher
beliefsystem.Thiscriterionaddressesthecomplexrelationalattachmentsystemsthat
ensuefollowingrepetitiveandpremeditatedabuseandlackofappropriateresponseat
thehandsofprimarycaretakersorothersinpositionsofresponsibility;
5.Alterationsinrelationshiptoothers,suchasnotbeingabletotrustthemotivesof
othersandnotbeingabletofeelintimatewiththem.Another"lessonofabuse"
internalizedbyvictim/survivorsisthatotherpeoplearevenalandselfserving,outto
getwhattheycanbywhatevermeansincludingusing/abusingothers.Abusesurvivors
maybeunawarethatotherpeoplecanbebenign,caregiving,andnotdangerous;
6.Somatizationand/ormedicalproblems.Thesesomaticreactionsandmedical
conditionsmayrelatedirectlytothetypeofabusesufferedandanyphysicaldamage
thatwascausedortheymaybemorediffuse.Theyhavebeenfoundtoinvolveallmajor
bodysystemsandtoincludemanypainsyndromes,medicalillnessesandsomatic
conditions;
7.Alterationsinsystemsofmeaning.Chronicallyabusedandtraumatizedindividuals
oftenfeelhopelessaboutfindinganyonetounderstandthemortheirsuffering.They
despairofbeingabletorecoverfromtheirpsychicanguish.
Researchhasshownthatindividualswhohavesymptomsthatmeetcriteriaforthe
complextraumadiagnosismayormaynothavetheadditionalsymptomsassociated
withstandardformsofPTSD(Ford&Kidd,,1998);thatis,theymayhaveallofthe
complextraumacriteriabutmayormaynothavePTSDsymptoms,perse.
Ofnote,manyofthemajorcharacteristicsresemblethesymptompictureofemotional
lability,relationalinstability,impulsivity,unstableselfstructuresenseofself,andself
harmtendenciesmostassociatedwithborderlinepersonalitydisorder(BPD;American
PsychiatricAssociation,1994).TheBPDdiagnosishascarriedenormousstigmainthe
treatmentcommunitywhereitcontinuestobeappliedpredominantlytowomenclients
inapejorativeway,usuallysignifyingthattheyareirrationalandbeyondhelp.Inrecent
years,thisdiagnosisthathascometobeunderstoodasaposttraumaticadaptationto
recurrentandseverechildhoodabuse,attachmenttrauma,andpersonalinvalidation,
givingtherapistsanotherwaytounderstandandtreatit.WeConceptualizingand
understandingBPDfromacomplextraumaperspectivecanassisttheclinicianinbeing
moreempathictowardstheclientandmoreevenhandedintermsoftreatmentand
personalreactions(countertransferenceandvicarioustrauma).
ComplexTreatment
Despitetheseshiftsinorientationunderstandingtheaftereffectsandtheirorigins,the
individualswithCPTSD/DESNOS(orBPD)diagnosiscanbeadifficultpopulationtotreat.
Psychotherapyisfraughtwithmanycomplications(Chu,1992;Linehan,1993)dueto
thenumberofissuessymptomstheclientmightexperience,issueswithpersonalsafety,
anddeficienciesintheabilitytoregulateaffectandtoapplyotherlifeskills.;Exposing
thesepatientsclientstoodirectlytotheirtraumahistoryintheabsenceoftheirability
tomaintainsafetyintheirlivesortoselfregulatestrongemotionscanleadto
retraumatization,andassociateddecompensation,andinabilitytofunction..
Inrecentyears,treatmentforpatientswiththe"classic"formofPTSDhasincreasingly
emphasizedtheuseofcognitivebehavioralinterventions(CBT),includingprolonged
exposure(PE)andcognitiverestructuring(CR),techniquesforwhichempiricalresearch
supporthasbecomeavailable(Foa,Friedman,Keane,Friedman,&Cohen,2008).The
researchsubstantiationoftheeffectivenessofthesetechniquesinamelioratingthe
oftenrefractorysymptomsofPTSDislaudable.Unfortunately,thewholesaleapplication
useofCBTexposuretechniquestoinpatientswithCPTSD/DESNOS(eventhosewho
clearlyhavePTSDsymptoms)maybeproblematicifappliedtooearlyintreatmentand
beforetheclientisstableandsafe.
CPTSD/DESNOS(eventhosewhoclearlymeetcriteriaforPTSD)maybeproblematicand
resurfacesomeoftheproblemsdescribedinthepreviousparagraph.Inresponsetothis,
therecommendedcourseoftreatmentfromthoseexperiencedintreatingCPTSD(Chu,
1998;Courtois,1999,2004;Courtois,Ford,&Cloitre,2009;Ford,Courtois,VanderHart,
Nijenhuis,&Steele,2005)involvesthesequencingofhealingtasksacrossseveralmain
stagesoftreatment.Thesestagesinclude(1)pretreatmentassessment,(2)earlystage
ofsafety,education,stabilization,skillbuilding,anddevelopmentofthetreatment
alliance,(3)middlestageoftraumaprocessingandresolution,and(4)latestageofself
andrelationaldevelopmentandlifechoiceThereisoverlappingtherapeuticwork
throughoutthestagesandoftenaneedtoreworkstabilizationskillsoverthecourseof
treatment.Butaseachstagebuildsonthepreviouswork,thetraumasurvivoracquires
growingcontrolandmastery,whichdirectlycounteractthepowerlessnessof
victimizationanditscontinuingaftereffects.
Thepretreatmentassessmentshouldbecomprehensive,withattentiontodiagnosis
withintheposttraumatic/dissociativespectrum,posttraumaticandothersymptoms,
safety,andcomorbidity(particularlysubstanceabuse,medicalillness,eatingdisorders,
andaffectivedisorders).ItisusefultocompleteallfiveaxesoftheDSM,withemphasis
oncurrentstressorsandavailableresourcesforuseinthedevelopmentofatreatment
plan.Thisisalsothetimetotakeabroadlookatneedsandresources,including
availablehealthcareresources,whichcansoeasilybelimitedbyaclientsdisabilityor
bymanagedcareinsurancecoverageorbyhis/herownmotivationoremotional
capacityfortreatment.
Theearlystagefocusesonsafety,stabilization,andestablishingthetreatmentframe
andthetherapeuticalliance.Measuredbymasteryofthenecessaryskillsandnotby
duration,thisstageoftreatmentmaybethemostimportantsinceitisdirectlyrelated
totheclientscapacitytofunction.Educationincomplextraumaandelementsofthe
humanresponsetotraumaprovideafoundationforskillbuilding.Skillstobedeveloped
includehealthyboundaries,safetyplanning,assertiveness,self-nurturingandself
soothing,emotionalmodulation,andstrategiestocontaintraumasymptomssuchas
spontaneousflashbacksanddissociativeepisodes.Additionally,attentiontowellness,
stressmanagementandanymedical/somaticconcernsisneeded.Medicationssuchas
antidepressantsandantianxietydrugsareoftenhelpfulandshouldbeconsideredto
targetposttraumaticsymptomsandthoseassociatedwithdepression,anxiety,and
sleepdisorders.
Themiddlestageoftreatmentbeginsonlyafterstabilizationskillshavebeendeveloped
andareutilizedasneeded.Thisstageinvolvesrevisitingandreworkingthetraumawith
careful processingtointegratetraumaticmaterialalongwithitsassociatedbutoften
avoidedemotion.Thisstagetypicallyinvolvestheexpressionofpainandprofoundgrief
butwiththesupportandwitnessingofthetherapist.Thereworkingoftraumaisalways
destabilizing,sotheskillslearnedintheearlystageoftreatmentprovidetheframeand
skillsetneededtofaceandintegratethepreviouslyavoidedtraumaticmaterial.Awide
varietyoftechniqueshavebeendevelopedforprocessingtraumathatareapplicableto
thistreatmentstageincludingprolongedorgraduatedexposure,cognitiveprocessing
therapy,cognitiverestructuring,narrativeexposure,andreprocessing,testimony,and
EyeMovementDesensitizationandReprocessing,tonamethemostcommon.
Thelatestageoftreatmentinvolvesidentityandselfesteemdevelopmentand
concurrentdevelopmentofimprovedrelationalskillsandrelationships.Theimportant
issuesofintimacy,sexuality,andcurrentlifechoices,includingwhethertocontinue
certainrelationshipsandvocationalchoicestypicallyoccursinthisstage,iftheyhave
notbeenaddressedearlier.Additionally,clientsatthisstageoftenencounteran
existentialcrisisassociatedwithanewsenseofselfandmuststrugglewiththemeaning
ofthenowintegratedtraumamemoriesandwiththelossestheyhaveendured.
Survivorsatthisstageoftenstruggletoembracelifewithrenewedenergyandhopefor
thefuture.Forsome,meaningmakingmayinvolveacommitmenttomakeadifference
intheworld,particularlywithrespecttodecreasingviolence.Thisissometimesreferred
toasa"survivormission."
Thecourseoftreatmentanditsdurationcanvaryquitedramaticallyandavarietyof
differenttreatmentstrategiesmightbeusedacrossthestagesoftreatment.Some
clientsstayintherapyforyears(especiallythosewiththemostextensivetrauma
historiesandthosewithinsecureattachmentstyles)maynevermovebeyondthefirst
stage,whileothersmovethroughthethreestagesinmuchlesstime,andstillothers
onlyengageintreatmentepisodicallyasneeded.Shortertermand"hybrid"approaches
(Cloitre,Cohen,&Koenen,2006;Ford&Russo,2006;Gold,2000)arenowunder
development.Theimportantconsiderationisthatnewanddifferentapproachestothe
treatmentofcomplextraumaarenowavailableandeffective.Survivorswhowereonce
confusedbytheirsymptomsandwhodespairedofeverreceivingunderstandingand
assistancenowhavetheopportunitytoreceiveeffectivetreatment,toheal,andtoget
theirlivesbackandontrack.
Christine A Courtois, PhD & Associates, PLC is a private practice that specializes
in the treatment of adults experiencing the effects of childhood incest/sexual abuse and
other types of trauma. Dr. Courtois has worked with these issues for 30 years and has
developed treatment approaches for complex posttraumatic and dissociative conditions
for which she has received international recognition.

References
AmericanPsychiatricAssociation(1980).Diagnosticandstatisticalmanualofmental
disorders(3rdEd.).Washington,D.C.:Author.
AmericanPsychiatricAssociation(2000).Diagnosticandstatisticalmanualofmental
disorderstextrevision.(4
th
Ed.Rev.).Washington,DC:Author.
Chu,J.A.(1998).Rebuildingshatteredlives:Theresponsibletreatmentofcomplexpost
traumaticanddissociativedisorders.NewYork:JohnWiley&Sons.
Cloitre,M.,Cohen,L.R.,&Koenen,K.C.(2006).Treatingsurvivorsofchildhoodabuse:
Psychotherapyfortheinterruptedlife.NewYork:TheGuilfordPress.
Courtois,C.A.(1999).Recollectionsofsexualabuse:Treatmentprinciplesandguidelines.
NewYork:W.W.Norton&Co.
Courtois,C.A.(2004).Complextrauma,complexreactions:Assessmentandtreatment.
Psychotherapy:Theory,Research,Practice,andTraining,41,412425.
Courtois,C.A.&Ford,J.D.(Eds.).(2009).Treatingcomplextraumaticstressdisorders:
Anevidencebasedguide.NewYork:TheGuilfordPress.
Courtois,C.A.,Ford,J.D.,&Cloitre,M.(2009).Bestpracticesinpsychotherapyfor
adults.InC.A.Courtois.&J.D.Ford(Eds.).Treatingcomplextraumaticstressdisorders:
Anevidencebasedguide(pp.82103).NewYork:TheGuilfordPress.
Foa,E.B.,Keane,T.M.,Friedman,M.J.,&Cohen,J.A.(Eds.).(2008).Effective
treatmentsforPTSD:PracticeguidelinesfromtheInternationalSocietyforTraumatic
StressStudies(2
nd
Ed.).NewYork:TheGuilfordPress.
Ford,J.D.,&Kidd,P.(1998).Earlychildhoodtraumaanddisordersofextremestressas
predictorsoftreatmentoutcomewithchronicposttraumaticstressdisorder.Journalof
TraumaticStress,11,4,743761.
Ford,J.D.,&Russo,E.(2006).Atraumafocused,presentcentered,emotionalself
regulationapproachtointegratedtreatmentforposttraumaticstressandaddiction:
TraumaAdaptiveRecoveryGroupEducationandTherapy(TARGET).AmericanJournalof
Psychotherapy,60,335355.
Ford,J.,Courtois,C.A.,VanderHart,O.,Nijenhuis,E.,&Steele,K.(October,2005).
Treatmentofthecomplexsequelaeofpsychologicaltrauma.JournalofTraumaticStress,
18,5.
Gold,S.N.(2000).Nottraumaalone:Therapyforchildabusesurvivorsinfamilyand
socialcontext.Philadelphia:BrunnerRoutledge:Taylor&FrancisGroup.
Herman,J.L.(1992a).ComplexPTSD:Asyndromeinsurvivorsofprolongedand
repeatedtrauma.JournalofTraumaticStress,3,377391.
Herman,J.L.(1992b).Traumaandrecovery:Theaftermathofviolencefromdomesticto
politicalterror.NewYork:BasicBooks.
vanderKolk,B.A.(2005).Developmentaltraumadisorder.PsychiatricAnnals,35,401
408.


Content may not be reproduced on websites without express permission. Please link instead.