Evidence of efficacy in studies of post-traumatic conditions is largely derived from studies in which variables are kept to a minimum. Extrapolation of treatments from uncomplicated disorders to complex conditions may therefore be called evidence-based without being evidenced.

Neglect of the complex: why psychotherapy for post-traumatic clinical presentations is often ineffective | BJPsych Bulletin

One of my (secondary) takeaways is that the Royal College of Psychiatrists makes a good argument against UK public health policy makers' endless endorsement of CBT.

The psychotherapy often provided for complex PTSD includes no multi-modal approach and those who fail to benefit may then be considered to be treatment-resistant. For patients with complex PTSD the ineffectiveness of psychiatric treatment and subsequent labelling as treatment resistance can then be attributed to an underlying personality disorder, often without adequate assessment or corroboration. Patients who are told that their lack of response to treatment is due to long-standing differences in one or more of the following: their thinking, their emotional regulation, their behaviour, and/or their interpersonal relationships, will feel further invalidation that confirms their inseparable differences from the rest of humanity. If everyone else can learn top-down regulation of distress in response to triggers, the failure to acquire these skills is held to imply deep-seated personality pathology.

Recognition of the neurobiological insults imposed by complex trauma and the implications for psychotherapeutic interventions | BJPsych Bulletin

Related article by some of the authors of the article above.

Conversations here about people considering themselves as "disordered" or "defective" or "too needy" or "too much" prompted me to post this. I don't like to think of anyone like that, and I've felt disconcerted after hearing others talk like this even though I've thought of myself like that at times, including recently.

It seems the more my therapist pathologizes my thinking or behaviors, the more my view of myself improves. Reverse psychology? Being a fighter; my survival nature coming back after all this time? Ha!

I've said over and over that CBT gets abused as a short-term therapy in cases where it needs to be incorporated into long-term therapy. Misused that way, it is an inevitable failure and that is a shame. I was SO very fortunate to fall upon a therapist who used CBT but most definitely not as a short-term therapy/solution. He saw it as a tool (not the only one) in my long-term therapy, and used thus, it was highly effective. CBT is only short-term perhaps in cases of mild and limited issues that can be fairly easily resolved. It can be used for trauma, but not as a stand-alone and certainly not as a quick fix.

[here today]

Originally Posted by Skies

Neglect of the complex: why psychotherapy for post-traumatic clinical presentations is often ineffective | BJPsych Bulletin
. . .

From the conclusion:

The first requirement is therefore to adopt an approach which will retain patients in therapy long enough for the therapist and patient to form a shared understanding of what is happening and to find a way of working together. This way must be found to be beneficial for the patient and sufficiently tolerable for the therapist so that the therapist does not avoid it.

This is a goal that may very well have worked for me.

Two key points that were missing in my last therapy:

1. The therapist and patient form a shared understanding of what is happening and find a way of working together.

2. This way must be found to be beneficial for the patient and sufficiently tolerable for the therapist so that the therapist does not avoid it.

I had a long history of therapy to begin with when I started with my last T. So I could have understood it if she had proposed those goals from the beginning. But for people just starting therapy, when the therapist suspects a complex client, it could still be helpful for the therapist alone to have that goal in mind as a possibility, and to discuss it as therapy progresses with the client so that they improve their ability to be on the same page and "form a shared understanding".

[here today]

Originally Posted by Skies

Recognition of the neurobiological insults imposed by complex trauma and the implications for psychotherapeutic interventions | BJPsych Bulletin

Related article by some of the authors of the article above.

Conversations here about people considering themselves as "disordered" or "defective" or "too needy" or "too much" prompted me to post this. I don't like to think of anyone like that, and I've felt disconcerted after hearing others talk like this even though I've thought of myself like that at times, including recently.

It seems the more my therapist pathologizes my thinking or behaviors, the more my view of myself improves. Reverse psychology? Being a fighter; my survival nature coming back after all this time? Ha!

I'm a fighter, too, but that was shamed by my family and culture of origin, and I needed them for survival more than my own self-esteem (so young me thought or felt ), so the "fight" went into problem-solving as well as self-fighting, the latter of which I have worked hard to abandon!

What I could not understand about my last T, and others, was her extreme (reactive) rejection of my outbursts of (relatively mild) curses, which I experienced as rejection of me, and which WAS a rejection of the young "angry" me which had been dissociated. Given that rejection, the "vulnerable me", which "angry me" protected?, did not make an appearance in that therapy. Nor could I understand that (perhaps) I needed to try to find some other therapist, which I was clueless about and had failed at so many times before.

Thanks, Skies. Both articles seemed to me to have a decent perspective and approach toward understanding the difficulties of complex clients and the difficulties in providing effective help. Very glad to see that!

I came across a book recently called "Wounded Personalities". That seems like a good description, at least for me and hopefully the public at large. The author was not a clinician, and seemed to be promoting a better understanding of conditions which end up with people getting Personality Disorder diagnoses.

[unaluna]

I realize im picking out bits here, but i feel gratified that i found backup in this article for warning my t that he was going to need supervision if he was going to work with me.

[BudFox]

Someone with PTSD who fails to benefit from therapy cannot be "treatment-resistant". Doesn't even make sense, since it's not treatment. This language signals delusion. They are lost in a fog of psychobabble and wishful thinking. Even referring to people with trauma or psycho-social problems as "patients" distorts reality.

These guys want so badly to be a legit branch of healthcare. It's not possible. There is just no way to make an artificial psuedo-relationship into an evidence-based intervention. Too many confounding variables in a human life. It's not replicable. Stop pretending.

And as usual no mention of the risk of harm. They seem only concerned with whether their interventions might be "ineffective". Does it even occur to them that a person with developmental trauma might suffer serious damage from a poorly controlled, engineered relationship with a stranger?

"The first opportunity some complex trauma patients will have for a stable and non-abusive relationship will be with the therapist."
We've all read about abusive and unstable therapy relationships on this forum. Apparently the authors haven't read such accounts. Nor have most therapists it seems. Many appear to live a fantasy world.

Originally Posted by here today

I came across a book recently called "Wounded Personalities". That seems like a good description, at least for me and hopefully the public at large. The author was not a clinician, and seemed to be promoting a better understanding of conditions which end up with people getting Personality Disorder diagnoses.

Sorry, I think that's pathologizing too. Good for you if you like it-but not something I encourage to describe people with trauma backgrounds. Not much different in my view than labeling someone who grew up with famous parents. See people as who they are rather than a product of their background. I don't mean to harp about language details, but I guess i am in a way.

Glad you liked the articles.

[here today]

Thanks for your view on labels and pathologizing. I feel like despite my best efforts my behavior and character have been pretty pathological sometimes. Also known as toxic. Or maybe it's all just "human"?

Again, all this despite my best efforts. The best I could do at the time.

I guess I just see a lot of judgmentalism in the world generally and maybe sometimes a rational judgment might be OK, if it doesn't imply a rejection of the person for being (temporarily or permanently) wounded, any more than we would for a physical injury. Still, though, if the person can't walk, they can't walk. Time was, years ago, people were made fun of for being "crippled". No one would think of that today.

I hear you.

I think I'm in an anti-pathologizing phase at the moment. Feeling 'normal' from my TMS treatment really opened my eyes to the negativity surrounding my treatment. It was like switch turned on, and i started seeing things without that ugly veil of grey that ostensibly tolerated paying someone to mercilessly point out of my defects for 45 mins. a week. I feel pretty well educated about my defects at this point; after close to 7 years of intensive therapy. Is there any more gain to that process; or is it time to really identify my strengths, and explore ways to harness them? And it's not necessarily either or, but the other side of each 'defect' perhaps lies a strength. Ying and yang.

What about the strengths of 'the wounded'? The resiliency, the character, courage, the resourcefulness of those of us with certain histories? I recently went to an art exhibit comprised solely of people who had long term histories of mental illness or anguish, and it was absolutely amazing!

I think the term wounded is triggering to me, as there's been times ive mentioned to my therapist about wanting to be put to sleep as done by veteranarians. Or animals who wander off to die or packs that abandon a member. Various ways to designate someone as less than human, or to alienate a person. Which is something the article also describes. Makes me think of schizoid anxieties too.

But it also signifies that someone has limitations. And sometimes or often we do, but that doesn't necessarily mean we should automatically resign ourselves to those limitations.

[Out There]

Oh , Yes , I'm in the UK and had someone who was a big CBT fan decide that's what I needed to stop my cycle of negative thinking. And when I didn't agree I was " non compliant , resistant and adopting a very narrow approach " ( I wanted to kill him , so I'll join you in. ) My EMDR T is trained in CBT and we do use some of it's techniques , but he says they put people in with minimal training to get the requirements met for seeing people in a certain amount of time that don't have the skills to handle serious trauma. It's all a bit political.

[CantExplain]

Originally Posted by here today

2. This way must be found to be beneficial for the patient and sufficiently tolerable for the therapist so that the therapist does not avoid it.

Also, sufficiently tolerable to the patient!

[satsuma]

When I first went to therapy, I had looked at the NHS choices website (for info, although I was going privately), and as CBT was recommended for most things, I assumed we would do CBT, and this is what I requested from my T. I was a bit discombobulated when he said that standard CBT was unlikely to work for me, and I would need something more in depth. Schema therapy is based on CBT and includes a lot of CBT, but also a lot of other techniques from gestalt, and it's a long term approach. On the NHS I think CBT is usually 6 - 12 sessions. My T knew that wouldn't be enough - and now I understand that he was right.

[here today]

Originally Posted by Skies

. . .
Feeling 'normal' from my TMS treatment really opened my eyes to the negativity surrounding my treatment. It was like switch turned on, and i started seeing things without that ugly veil of grey that ostensibly tolerated paying someone to mercilessly point out of my defects for 45 mins. a week. . . .

That's awesome!!! I'm "over" obsessing about my defects, too. Don't have insurance that would cover TMS. I'll just take your word for it, and believe it or not, that helps me believe it's possible to lift the veil of grey here, too!

Originally Posted by satsuma

When I first went to therapy, I had looked at the NHS choices website (for info, although I was going privately), and as CBT was recommended for most things, I assumed we would do CBT, and this is what I requested from my T. I was a bit discombobulated when he said that standard CBT was unlikely to work for me, and I would need something more in depth. Schema therapy is based on CBT and includes a lot of CBT, but also a lot of other techniques from gestalt, and it's a long term approach. On the NHS I think CBT is usually 6 - 12 sessions. My T knew that wouldn't be enough - and now I understand that he was right.

Satsuma-did NHS cover therapy other than CBT for you or did you have to go private? Schema therapy sounds good, I'd do it if I had to start therapy over again.

Originally Posted by here today

That's awesome!!! I'm "over" obsessing about my defects, too. Don't have insurance that would cover TMS. I'll just take your word for it, and believe it or not, that helps me believe it's possible to lift the veil of grey here, too!

It wasn't me obsessing over my shortcomings, not for a long time, this was me realizing my therapist was! Of course I'm exaggerating a bit-he helps me understand myself, but he does way to much pointing out my shortcomings and negative things about me, framing everything in a negative light, like he only sees the worst in me.

Most insurances cover TMS now-have you checked lately? You can go to a place for a free consultation-they will negotiate with insurance. If you haven't checked lately, it would be worth a try.

[satsuma]

Originally Posted by Skies

Satsuma-did NHS cover therapy other than CBT for you or did you have to go private? Schema therapy sounds good, I'd do it if I had to start therapy over again.

I went privately. It was very expensive and took a big chunk of my monthly income to start with, but I feel it was 100% worth it.
I'm not sure, but I don't think I would have been offered anything beyond CBT on the NHS, because although my problems are complex, I am a high-achiever and highly functioning. So I don't think I would have been considered a priority. Also, I didn't really feel comfortable sharing everything with my GP. In the NHS you access everything initially through your GP.
I totally recommend schema therapy if it's possible for you. I've had a very positive experience of this therapy.

[feileacan]

I have never had much faith into "evidence-based" therapies, especially when you have a complex condition. It's obvious that in order to just show basically anything with a reasonable effect size regarding something as complex as psychotherapy, it is absolutely necessary to simplify it to the point where the results become statistically significant but in reality are completely useless.

I do think that psychotherapy has quite many similarities to science though, I mean the process in general.

First of all, in both science and psychotherapy, you actually don't know what comes out or if anything good and useful comes out at all. You start with a certain amount of faith that there is a chance for some success.

Secondly, both scientific and psychotherapeutic processes require quite a lot of resilience. Most probably there are periods where you have to endure uncertainty and not understanding what's going on. But in order to get something out you have to keep trying. You try one way - it doesn't work, you try another way - it doesn't work. Finally, during this process of trial and error you have hopefully learned enough about your problem that you are finally able to gain some useful insight about it. But the process is neither linear nor clear but is very satisfactory and rewarding if something finally comes out - both in science and in psychotherapy. At least this has been my experience with both of those disciplines.

[here today]

But when you're wandering in the woods, lost, for years on end, until you're almost out of lifetime . . .and know some people who DID give out of lifetime without anything very satisfactory and rewarding. . .maybe it's the engineer in me who says "There's got to be a better way!"

But I've got a bit of a scientist in me, too -- I agree that certainly helped.

[feileacan]

Originally Posted by here today

But when you're wandering in the woods, lost, for years on end, until you're almost out of lifetime . . .and know some people who DID give out of lifetime without anything very satisfactory and rewarding. . .maybe it's the engineer in me who says "There's got to be a better way!"

I guess there's then also another common aspect in scientific and psychotherapy process - you have to be able to judge when there's no point in going further in that particular direction. You have to be able to tolerate the losses related to giving up something you have invested in quite a lot but that most probably doesn't lead anywhere according to your current judgement. The trickiest part is that there isn't really anyone there to tell you what would be the right thing to do and you have to decide it on your own.

[here today]

There again, because of the limitations I went into into therapy with, I was not

. . . able to judge when there's no point in going further in that particular direction. You have to be able to tolerate the losses related to giving up something you have invested in quite a lot but that most probably doesn't lead anywhere according to your current judgement. The trickiest part is that there isn't really anyone there to tell you what would be the right thing to do and you have to decide it on your own.

I was not able to navigate the tricky part well because I lacked an integrated, flexible sense of self. Again, what I went into therapy with.

I was diagnosed with PDNOS 7 years ago, after a breakdown 15 years ago. Before that I believe I would have qualified for an OCPD diagnosis if the clinicians were diagnosing PD's then. I certainly functioned and looked at the world in a way that is similar to people with that diagnosis.

While the PD diagnoses may be "pathologizing" labels, they COULD also be used as tools by the clinicians to help pinpoint likely problem areas that the clients cannot see themselves, because of the nature of personality disorders!

Schema therapy was not available when I started therapy, but it looks to me like it CAN help to identify and maybe address limitations clients come into therapy with. So me, too, if I were starting out with therapy now, that's what I would look to -- if I knew then what I know now about my limitations back then! Which I didn't.

[feileacan]

Originally Posted by here today

I was not able to navigate the tricky part well because I lacked an integrated, flexible sense of self. Again, what I went into therapy with.

... if I knew then what I know now about my limitations back then! Which I didn't.

Yep, that all makes awfully lot of sense. But I have no idea how could you get to know those things you know now without going through this process that brought you to these realisations.

Originally Posted by BudFox

And as usual no mention of the risk of harm. They seem only concerned with whether their interventions might be "ineffective". Does it even occur to them that a person with developmental trauma might suffer serious damage from a poorly controlled, engineered relationship with a stranger?

That wasn't the focus of the article, but there was mention of it:

The wrong therapy, by the wrong therapist or with the wrong timing (or a combination thereof) may be psychonoxious.

They also mentioned the need to collect data on those who dropped out.

To keep in line with feileacan's points, a scientific study would document everything that went wrong as much as it would document what went right, so there would be more data on that aspect to add to the article, i agree with you. I think they framed the article to inform public health policy rather than information about the treatments themselves, but that could be an improvement.

The journal accepts comments to the articles, perhaps if you or anyone submit a comment in reply to the article, the authors will consider adding that point to their next paper. It's open-access, so there are no restrictions to copyright as long as the citation is there, so you (or anyone) could repost the whole article on Psych Central, submitting your commentary.

I think open access articles help spread the word about important issues that affect public health and that this group did a great job at explaining why services are inadequate for certain patient populations.

[BudFox]

Originally Posted by Out There

Oh , Yes , I'm in the UK and had someone who was a big CBT fan decide that's what I needed to stop my cycle of negative thinking.

CBT seems like psychotherapy's response to psychiatry's drugs... see we also have a "drug" that can be used to control symptoms (while leaving root causes untouched). Seems negative thoughts are an adaptation, and rather than stopping them, the point should be to understand their origin, especially for those with trauma history or significant difficulties.

[Out There]

Originally Posted by here today

But when you're wandering in the woods, lost, for years on end, until you're almost out of lifetime . . .and know some people who DID give out of lifetime without anything very satisfactory and rewarding. . .maybe it's the engineer in me who says "There's got to be a better way!"

But I've got a bit of a scientist in me, too -- I agree that certainly helped.

I had to get the scientist ( that was my job ) that analysed things to move out of the way to feeling things. I recently started some meditation classes and it became quite clear that one aspect of trauma is it's being held in the body ( 12 CBT sessions and you SHOULD be fine ). Ugh - give me Bessel van der Kolk any day.