Psychoeducation

a) Models of simple PTSD and how multiple trauma complicates presentation (memory models) b) Explaining the impact of developmental trauma c) Explaining windows of tolerance (level of arousal tolerable to the client) d) Explaining dissociation e) Explaining symptoms and emotional responses

Psychoeducation for CPTSD usually features an explanation of PTSD, including the reason for intrusive symptoms and justification for exposure work, as well as an explanation of symptoms and skills deficits. This aims to increase the individual’s understanding of the difficulties, commitment to therapy, and self-compassion, and reduce shame. Frequently covered topics are summarized below.

a) Models of PTSD

The three main models used to explain PTSD are:

• Ehlers and Clark cognitive model
• Brewin’s dual representation theory of PTSD
• Foa’s fear network.

According to the Ehlers and Clark cognitive model (Ehlers and Clark, 2000), PTSD becomes persistent when, in processing the traumatic event and/or its sequelae, the individual perceives a continuous sense of serious current threat. Two key processes are implicated:

• Negative appraisals of the trauma and its sequelae
• Disturbance of autobiographical memory, characterized by strong perceptual memories (such as intrusive images and emotions) that are disconnected from their context and an intellectual understanding of the trauma.

This leads to behavioral and cognitive responses and strategies (e.g., avoidance) designed to reduce the perceived level of threat and associated distress. Although effective in the short term, these strategies prevent cognitive change in the longer term and hence maintain post-traumatic stress.

Brewin’s dual representation theory of PTSD (Brewin et al., 1996; Brewin and Saunders, 2001; updated in Brewin, 2011) describes two components of memory representations: sensation-based (S-rep) and contextual (C-rep). In healthy memory, the two components are paired and form the ‘hot’ and ‘cold’ parts of the memory respectively. Under extreme stress, the hippocampus becomes significantly less active, and the amygdala significantly more active. Under these conditions, the C-rep is weakened and, rarely, can be absent at the most traumatic moment of a memory. This means that the S-rep loses its context (so is not integrated with time, place, and surrounding knowledge) and can only be retrieved involuntarily, and is associated with a much more powerful autonomic response. These are experienced in PTSD as flashbacks.

Foa’s fear network (Foa et al., 1992) proposes that trauma forms a fear network in long-term memory, which is activated by trauma-related cues. Information from the network enters consciousness and leads to intrusions and attempts to avoid and suppress memories. Successful resolution of the trauma requires integration of the fear network and existing memory structures. However, this is challenged by the unpredictable and uncontrollable nature of trauma; disruption of cognitive processes of attention and memory at the time of trauma; and the creation of a disjointed and fragmented fear network.

The Ehlers and Clark (2000) model is easily explained to clients and offers a helpful way to illustrate the need for an exposure-based intervention and tackling behavioral avoidance. It is commonly used to guide formulation in people with PTSD. Brewin’s model has neuropsychological support and is useful as a rationale for the usefulness of imagery and nightmare rescripting, while Foa’s model is a useful way of explaining the impact of multiple trauma and as a rationale for treatment. It is an important part of psychoeducation for narrative exposure therapy (NET) and can also be useful in introducing eye movement desensitization and reprocessing (EMDR) therapy. Nevertheless, it is important to note that all these theoretical conceptualizations have been developed primarily to explain PTSD rather than CPTSD.

Models of PTSD can often be introduced to clients using metaphors or simple diagrams. Common metaphors include the image of a linen cupboard, a filing cabinet, or a photo album. Some clients find these metaphors helpful, while others prefer a simple explanation of how memories are stored in the brain.

b) Explaining CPTSD, including developmental trauma

Attachment theory forms a useful basis for explanations of developmental trauma, and some clients may benefit from reading about this. The foundations for difficulties in recognizing and regulating affect can be explained through attachment and reciprocity. A parent/carer’s ability to resonate with an infant’s internal states and translate them into actions and words appropriate to the child’s stage of development will eventually lead to the child’s ability to connect internal states with words. Mother-infant synchrony contributes to the organization and integration of neural networks and the development of self-regulation.

At times of threat or distress, our attachment system is activated, and we revert to our underlying internal working models. If these are organized and stable, thanks to reliable and consistent carer response to infant distress, the individual will be able to regulate their emotional experiences in adulthood. Where this is not the case, the individual will have difficulty identifying and safely regulating their emotions and will be more likely to find them overwhelming.

c) Explaining windows of tolerance

A person’s window of tolerance (Ogden et al., 2006) is sculpted by their early attachment relationships. Auto-regulation is the ability to calm oneself when arousal rises (sympathetic activation) to the upper limits of the window of tolerance or to increase activity when arousal drops (parasympathetic activation). Many people with CPTSD show affect intolerance in response to under- or over-activity of the stress response system. Such inability to tolerate intense emotion may result in, for example, addictive behavior, self-harm (to discharge emotion), or dissociation. Alternatively, an individual may experience ongoing low activation, such that they spend considerable periods in a numb, inert, or disengaged state.

A person’s window of tolerance narrows as a consequence of repeated trauma and influences, resulting in:

• Reduced emotion regulation abilities
• Reduced relational capacities
• Reduced capacity for attention and consciousness
• Negative influence on belief systems
• Increased somatic distress or disorganization.

Treatment of CPTSD builds emotional resilience and integrative capacity, which can only happen with an increased window of tolerance.

d) Explaining dissociation

Dissociation is defined in DSM-5 (2013) as ‘disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment’. Some people dissociate during trauma (Holmes et al., 2005; Murray et al., 2002; Ozer et al., 2003). Such peritraumatic dissociation may be experienced as spontaneously ‘going blank’, ‘switching off’, or ‘leaving’ their body (derealization or depersonalization) and may be an attempt by the individual to distance themselves from the distress they are feeling. Consequently, the traumatic memory or parts of the memory can become inaccessible to conscious awareness (Wright et al., 2006). The encoding of the memory can become altered by traumatic experiences resulting in fragmented yet vivid sensory-perceptual memories or ‘flashbacks’ (Grey and Holmes, 2008). Recalling traumatic events might then trigger dissociation.

Even when there is no peritraumatic dissociation, recall of traumatic memories can result in a parasympathetic response that makes dissociation likely (Schauer et al., 2011).

The theory of structural dissociation of the personality postulates that the personality of traumatized individuals is unduly divided into two basic types of dissociative subsystems or parts (Nijenhuis et al., 2010). One type (referred to as the Apparently Normal Part/s) primarily functions in line with the individual’s daily life goals; the other type (Emotional Parts) are dissociative parts, fixated on the trauma and primarily serving a defensive function. The more severe and chronic the traumatization, the more dissociative parts are likely to exist.

Helping clients understand why they may have developed different parts as a means of coping with repeated trauma may serve to increase understanding of the disintegration often experienced in CPTSD. This model may also offer an integrated formulation of the multiple diagnoses that many people with CPTSD have acquired.

People with CPTSD often present with a wide range of symptoms associated with their attempts to manage the emotional distress linked to trauma, resulting in multiple diagnoses to account for these symptoms. For this reason, it is essential that an individualized formulation is developed that brings together the range of symptoms and difficulties experienced by the individual.