Evidence-Based Practice for Complex Trauma

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According to the National Association of Social Workers, “EBP [evidence-based practice] is a process in which the practitioner combines well-researched interventions with clinical experience, ethics, client preferences, and culture to guide and inform the delivery of treatments and services.” In psychology and clinical social work, researchers compare a specific kind of treatment or medication to other kinds of treatment or to no treatment at all. This research helps build evidence that what we do actually works.

Two Kinds of Trauma, Two Kinds of Evidence

When we think of trauma, we usually think of Post-Traumatic Stress Disorder (PTSD), which is often limited to one event, like a car accident, or to one time period, like a deployment to a war zone. I absolutely do not want to minimize the effects of PTSD, but it is a distinctly different problem from the complex trauma I usually work with, and it has its own evidence base.

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According to the Department of Veterans Affairs, evidence-based treatments for PTSD include cognitive behavioral therapy (CBT) and eye-movement desensitization and reprocessing (EMDR), among others. There is good evidence for some medications for treating PTSD as well.

Complex trauma, first described by Dr. Judith Herman in 1988, is different from “regular trauma” in that it happens over a long period of time, can be repetitive, and is based in interpersonal relationships. Family disfunction, abuse, or even toxic workplaces can cause symptoms that look like PTSD, including anxiety, hypervigilance, problems sleeping and eating, reexperiencing negative events, and more. However, complex trauma also affects a client’s core sense of self, leading to self-doubt, self-criticism, dissociation, and other problems not always seen in “standard” PTSD.

And unfortunately, the evidence base for PTSD doesn’t transfer to complex trauma; although cognitive-behavioral therapy and EMDR can help with complex trauma, sometimes they can be unhelpful if they are not integrated into a total treatment plan.

New Research Supports Old Ideas for Complex Trauma

I was thrilled to see a new peer-reviewed research article this month in PLOS Medicine which specifically addressed identifying solid evidence for complex trauma. These researchers reviewed many other studies, evaluated and consolidated their conclusions, and identified interventions with the best results. This is known as a systematic review and it is one of the best possible forms of evidence.

Happily, the evidence supports much of what the complex trauma therapy community has been doing: medications, while they can help, are less effective in individuals with complex trauma. While medication is critical for stability and mood management, medication alone will not make a significant difference for complex trauma.

Many kinds of therapy will help individuals who have experienced complex trauma, but the most effective treatments were trauma-informed and trauma-focused. This supports our understanding that no matter what kind of treatment we are using, the foundational steps are creating safety, processing the trauma, and then developing a new sense of self.

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Finally, the research shows that using combinations of trauma-focused therapies and skills-based strategies in a flexible manner depending on symptom presentation is evidence-based. The article describes “multicomponent” treatments that draw on skills for emotion regulation as well as interventions to process trauma as being most effective.

What This Means in My Office

This article provided strong evidence for the process I use with clients with complex trauma, which is tremendously validating. It is important to me to provide the best care possible for my clients, and this new evidence for clients who have experienced complex trauma lets me know I am doing just that.

Whit Davison, LMSW

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