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

  • Frank M. Corrigan (a1) and Alastair M. Hull (a2)
Summary

Considerable research has been conducted on particular approaches to the psychotherapy of post-traumatic stress disorder (PTSD). However, the evidence indicates that modalities tested in randomised controlled trials (RCTs) are far from 100% applicable and effective and the RCT model itself is inadequate for evaluating treatments of conditions with complex presentations and frequently multiple comorbidities. Evidence at levels 2 and 3 cannot be ignored. Expert-led interventions consistent with the emerging understanding of affective neuroscience are needed and not the unthinking application of a dominant therapeutic paradigm with evidence for PTSD but not complex PTSD. The over-optimistic claims for the effectiveness of cognitive–behavioural therapy (CBT) and misrepresentation of other approaches do not best serve a group of patients greatly in need of help; excluding individuals with such disorders as untreatable or treatment-resistant when viable alternatives exist is not acceptable.

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Copyright
This is an open-access article published by the Royal College of Psychiatrists and distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Corresponding author
Correspondence to Frank M. Corrigan (frank.corrigan@nhs.net)
Footnotes
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See Bulletin comment, p. 100, this issue.

Declaration of interest

None.

Footnotes
References
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BJPsych Bulletin
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  • EISSN: 2056-4708
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Recognition of the neurobiological insults imposed by complex trauma and the implications for psychotherapeutic interventions

  • Frank M. Corrigan (a1) and Alastair M. Hull (a2)
Submit a response

eLetters

Body awareness and complex trauma

I agree that there is a need to think beyond RCT evidence bases in this context, and that there is a clear disconnect between existing services and systems and clinical reality. However, there is a missing piece in the discussion of approaches consistent with the evolving understanding of the neurobiological underpinnings of traumatic experiences and reactions.

Complex trauma tends to impair the development of, or damage, a person’s connection to their felt bodily sense of self. An individual may be literally unable to feel the whole or parts of their body (1). Felt body awareness involves interoceptive pathways, including parts of the insular cortex and anterior cingulate cortex (2). There is evidence indicating that parts of the brain associated with interoception are deeply compromised by trauma (3). Lacking a felt bodily sense of self has wider implications than just lacking a sense of safety in the body or a grounding resource needed for other treatment modalities to be possible. Without a felt bodily sense of self there is a very fundamental disconnection from needs and an impaired sense of agency: a sense of not knowing what we feel, what we want or what to do about it. This felt bodily sense of self is our most basic sense of self, and the basis of having any sort of sense of self at all (4). Restoring this felt bodily sense of self is central to working with complex trauma.



Somatic approaches bring the body into psychotherapy in different ways. Body awareness may be understood as a resource (as in the Comprehensive Resource Model). The therapy may bring attention to and work with the physical representations or somatic residues of emotional experiences (as in Somatic Experiencing and Sensorimotor Psychotherapy). But there is also a place for interventions that focus primarily on building the capacity to notice and interact with shifting bodily states. Such interventions create repeated opportunities to experience a felt, bodily sense of self and agency, without bringing in interpretation, meaning-making or the processing of trauma. Interventions like this need to establish, and consistently maintain, a relational environment that creates opportunities to experience non-reactive, non-dissociative embodiment for people whose states of being may often be dominated by reactivity and/or dissociation. One such relationally-focused body awareness intervention is Trauma Sensitive Yoga, as developed by David Emerson and others at the Trauma Center at JRI in Boston (5). This approach is informed by research in the fields of trauma, attachment and neuroscience. It encourages in-the-moment body awareness whilst also acknowledging the relational dynamics of control and compliance, often so problematic in complex trauma. This is reflected in, amongst other things, invitational language which repeatedly emphasises that the person participating always has choice as to what they do with their body. Despite the challenges associated with RCT evidence in this area, this approach in fact has a published RCT behind it (6).

Why an intervention like this works is an open question. One might hypothesise that it strengthens interoceptive pathways compromised by trauma. Perhaps another way of looking at it is that it is as close as a treatment gets (whilst still taking training, supervision, protocols and research seriously) to not actually feeling like a treatment. This goes for both the person participating in treatment and the person facilitating it. The ‘mechanism’ involved is perhaps shared, real, lived, in-the-moment experience of noticing and interacting with shifting bodily states, of having an embodied sense of self. This non-treatment-like ‘feel’ is also pertinent in light of issues around barriers to people seeking help for complex trauma.

References:

1.van der Kolk B. The Body Keeps the Score Brain, Mind and Body in the Healing of Trauma, pp. 87-98. Viking, 2014

2. Craig A D. Significance of the insula for the evolution of human awareness of feelings from the body. Ann. N.Y. Acad. Sci. 1225 (2011) 72–82

3. Herringa, R, Phillips, M, Insana, S, and Germain, A. Post traumatic stress symptoms correlate with smaller subgenual cingualte, caudate, and insula volumes in unmedicated combat veterans. Psychiatry Research, 203(2-3), 139-1454

4.Damasio, A. R. (2000) Sources of the Self, Vintage, 2000

5.Emerson, D. Trauma Sensitive Yoga in Therapy: Bringing the Body into Treatment. Norton, 2015

6.van der Kolk, B. Stone, L. West, J. Rhodes, A. Emerson, D. Suvak, M. and Spinazzola, J. Yoga as an Adjunctive Treatment for Posttraumatic Stress Disorder: A Randomized Controlled Trial. Journal of Clinical Psychiatry 2014;75(6):e559-e565

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