Trauma Informed

Practice when
Working with
Complex PTSD

PESI 21 April 2022

Christiane Sanderson

©Christiane Sanderson 2022

 Aims and Objectives
o introduce the fundamental principles of
trauma informed practice to enable clinicians
to view clients experiences through the lens
of trauma
o Trauma Informed Practice as a scaffold to
support their preferred therapeutic model to
manage trauma symptoms
o Phased Oriented Model of Trauma Therapy
o The three stages of stabilisation, processing
and integration
o Range of grounding and affect regulation
skills to increase distress tolerance and
resilience
o How these can best be employed e to create
a safe, predictable and consistent therapeutic
o How to become a more trauma wise
practitioner

©Christiane Sanderson 2022

 Range of Trauma

o Natural Disasters - flooding, tsunamis,

hurricanes, earthquakes, famine…
o Man Made Disasters – terrorist attacks, war,
mass genocide…
o Accidents – cars, bus, train, plane crashes…
o Attacks and Violence – mugging, burglary,
assaults…
o Interpersonal violence – torture, hostage,
rape, domestic violence, child abuse, human
trafficking, institutional abuse, religious abuse,
elderly abuse, abuse by professionals…
o Developmental Trauma
o Complex Trauma – repeated, prolonged
o Collective Trauma

©Christiane Sanderson 2022

 Types of Trauma
o Type I (single event)
o Type II (repeated) Trauma – Terr 1991
o Type IIA (multiple traumas and stable
backgrounds, intact resources to
separate individual events) Rothschild,
2000
o Type IIB (Multiple traumas so
overwhelming cannot separate them)
o Type IIB (R) – stable background,
complexity of trauma overwhelming that
resilience is impaired
o Type IIB (nR) – never developed
resources for resilience
o Post Traumatic Stress Disorder
o Complex Post Traumatic Stress Disorder
©Christiane Sanderson 2022
 Post-Traumatic Stress Disorder (PTSD) and Complex PTSD

PTSD Subtype - PTSD with Prominent Complex PTSD

Dissociative Symptoms

Sense of Threat Sense of Threat Sense of Threat and Shame

Intrusion Symptoms – re- Intrusion Symptoms - re- Intrusion Symptoms – re-
experiencing experiencing experiencing
Avoidance Symptoms Avoidance Symptoms Avoidance Symptoms

Alterations in Cognitions and Alterations in Cognitions and Alterations in Cognitions and

Mood Mood Mood

Alterations in Arousal and Alterations in Arousal and Alterations in Arousal and Reactivity
Reactivity Reactivity

Depersonalisation Dissociative Symptoms

Derealisation Persistent beliefs about oneself as

diminished - Negative Self-concept
Interpersonal Disturbances -
difficulties in relationships
©Christiane Sanderson 2022
2019
 Psychobiological Impact of
Trauma
o Psycho-biological survival system activated,
outside of conscious awareness and control,
cascade of neuro-chemicals
o Threat activation - Flight, fight, freeze
response
o Emotional dysregulation - hyper or hypo-
arousal
o Sympathetic Autonomic Nervous system
activation –fight, flight - ‘quick and dirty’,
accelerator, hyperfreeze, facilitates recovery,
through seeking help, crying, shaking
preparing
o Parasympathetic Autonomic Nervous
System – immobilisation, freeze threat
remains online, reduces processing,
disorganisation, PTSD and dissociative
disorders
o Toxic stress
o Somatic changes
o Impact on attachment system -
approach/avoid
 Impact on Self and Relationships
o Dissociation and dissociative states -
disconnection from body, fragmented self
structures
o Distortion of reality - distorted perceptions
and cognitions
o Unprocessed memories - Verbally accessible
memory system (VAM’s) vs Situationally
accessible memory system (SAM’s)
o Changed perception of self, others and the
world - shattered assumptions
o Shame - self blame, guilt
o Changes in sense of self – false self
Activation or deactivation of the
attachment system
o Impaired trust - fear of relationships,
intimacy, lack of relational worth
o Loss and mourning

©Christiane Sanderson 2022

 Trauma and Resilience
o Temperament – genetic predispositions,
arousability, anxiety, impulsivity,
personality variables Realistic Reach out
expectations and connect
o Ability to process trauma – reflective and goals to others
functioning, mentalisation, can crack or
create psychic space ( Alayarian, 2011)
Openminded Healthy
o Cognitive processing capacity and flexible boundaries
o Sense of agency
o Support network and facilitative
environment can change Purpose and
meaning
Life skills
developmental pathways irrespective of
temperament and how well individuals Care and
cop, nurture can overcome nature support

o Compartmentalisation - healthy
dissociation
o Cross-cultural factors
©Christiane Sanderson 2022
 The Power Threat Meaning Framework
(Johnstone and Boyle, 2018)
o Framework to understand distress, confusion,
fear, despair - as well as troubled or troubling
behaviour within social and relationship context
o Alternative to psychiatric diagnosis and
formulation
o Recognises emotional distress and behaviours as
threat responses to past experiences – adaptive
survival strategies
o ‘Symptoms’ are attempts to make sense of
difficult experiences – adaptations, shame,
isolation, fear and guilt.
o Social perception – stigmatisation, social injustice
o Focus on ‘what happened to you’ rather than
‘what is wrong with you?’ – ‘How did it affect
you? ‘What sense did you make of it?’ ’What did
you have to do to survive?, ‘What are your
strengths?’ ‘What is your story?’
o Validation of narrative
o Increases access to power and resources
©Christiane Sanderson 2022
 What kind of threats….
o Relational – threats of rejection, abandonment, isolation
o Emotional – threats of overwhelming emotions, loss of
control
o Social/community – threats to social roles, social status,
community links, self in the eyes of others
o Economic/material – threats to financial security, housing,
being able to meet basic needs
o Environmental – threats to safety and security, to links
with the natural world – living in a high crime area or
neglected and rundown area with no natural features
o Bodily – threats of violence, bodily invasion, physical ill
health
o Value base – threats to beliefs and basic values
o Meaning making – threats to ability to create valued
meanings about important aspects of your life/ imposition
of others’ meanings

©Christiane Sanderson 2022

 Fundamental Principles of Trauma
Informed Practice
o Awareness of trauma and its impact
o Look at trauma through the eyes of each
individual
o Create safety – culturally, emotionally and
physically
o Promote choices
o Transparency and trustworthiness
o Collaboration and mutuality
o Empowerment
o Awareness of cultural contexts and the
impact of racism, poverty, marginalisation
and stigmatisation
o Recognise the strengths of the individual
o Recovery from trauma is possible – there is
HOPE!

©Christiane Sanderson 2022

 Facilitating Trauma Informed Practice
o Trustworthiness – authenticity, transparency,
consistency, predictability
o Highly attuned caring relationship
o Collaboration and mutual exchange of
knowledge - psychoeducation, formulation,
healing process
o Aim to minimise and mitigate power imbalances
and differentials
o Awareness of the Power Threat Meaning
Framework
o Empowerment
o Intersectionality
o Cultural humility (Tervalon and Murray-Garcia,
1988)
o Peer support – community, belongingness
o Triphasic Model of Trauma ( Baranowsky, Gentry,
& Schultz, 2004; Herman, 1992).

©Christiane Sanderson 2022

 The Phased Oriented Approach to Trauma
Recovery

o Safety and Stabilisation, Rememberance and

Mourning, Reconnection (Herman, 1992)
o Ensure safety, identify and cultivate resources,
build resilience, promote self care, support
network…
o 1. Stabilisation - psychoeducation, regulation Phase I
of arousal, restore internal control, Phase II
mindfulness, grounding, affect regulation, Phase III
Stabilisatio Processin
window of tolerance .. Integration
n g
o 2. Processing of Trauma – realisation of the Meaning,
Safety, Processing building
past, trauma experiences, split off feelings, the trauma
recurring themes, mourning, develop a grounding, resilience,
resources, experience reconnection
coherent narrative
psycho-
o 3. Integration – restore meaning, integrate education
experiences, reconnection, post traumatic
growth
©Christiane Sanderson 2022
 The Phased Oriented Approach to Trauma Recovery
Phase 1: Stabilisation
Psychoeducation – . trauma , sexual
arousal cycle, distortion of reality.
Link current symptoms to past
experiences, adaptations to trauma,
PTM framework
Establish safe environment and
therapeutic relationship - build
trust, connection, relational
Phase 2: Processing
Processing and reappraisal of the
unresolved trauma - traumatic
experiences, memories, flashbacks,
memories, recurring themes
Process recurring themes – shame,
fear of closeness, connection,
sexuality, relational difficulties,
Phase 3: Integration
Consolidating treatment gains
Continue to Integrate experiences
reclaim the body, spontaneity and
sexuality

Symptom management – restore Integrate memories into an adaptive Reconnection to self and others –
inner control, dissociation, self- representation of self, relationships compassion, empathy
harm, substance misuse, risk taking, and the world
shame
Emotional Regulation - re-regulate Process split-off experiences and Restore meaning and reality -
the nervous system, expand Window feelings - restore inner experiencing resolution and recovery
of Tolerance
Skills training and resourcing - Realisation of the past and make Reintegration - social engagement
increase emotional, social and meaning – legitimising experiences relationships, work, education, life
psychological competencies ©Christiane Sanderson 2019

Grounding techniques, noticing, Develop a coherent narrative Build resilience and authentic
mindfulness, embodiment pride
Mentalisation ©Christiane and
Remembrance Sanderson 2022
mourning Post traumatic Growth
 Applying the Phased Oriented
Approach to Trauma Recovery
o Framework and scaffold for trauma work
o Readiness - stages are not determined by
time but readiness/mastery of skills
o Phases are not linear and clients can
oscillate
o Some never go beyond phase one – need
to be accepting of that
o Processing phase is not just about
memory recall – processing of feelings,
deception, betrayal, distortion of reality
o Phase One and Three could be
conducted through groupwork
o Phase One can be applied in myriad
settings – short term counselling,
addiction services, trauma services…

©Christiane Sanderson 2022

Phase One – Safety and Stabilisation
o Safety - , reducing symptoms and skills training,
to increase emotional, social and psychological
competencies, reducing unsafe behaviours, e.g.
self harm, and risk taking, and establishing a
safe environment
o Psychoeducation
o Regulation of arousal – emotional self
regulation, restore internal control, expand
Window of Tolerance
o Identify triggers - increase mastery
o Identify and cultivate resources
o Somatic Safety
o Grounding skills and Mindfulness
o Grounding at beginning and end of session
o Move to Phase 2 - knowing when enough
stabilisation has occurred – to move to Phase
Two or refer

©Christiane Sanderson 2022

 Stabilisation
o Emotional regulation – expand Window of
Tolerance
o Combine top-down and bottom-up regulation -
Increase distress tolerance and improve stress
resilience
o Slowing down – mindfulness, reflection
o Keeping hands busy – tangle toys, stress balls,
juggling balls, knitting…
o Distraction – crossword puzzles, puzzle books,
suduko,, playing a musical instrument, painting,
sculpting, writing, movement, going for a walk…
o Immersion – grounding hobby, baking, jigsaw
puzzles, colouring books computer games,
meditation,
o Safe Place - all sensory channels
o Grounding skills
o Mood basket
o Relaxation Kit – candle, blanket, treat
©Christiane Sanderson 2022
 Grounding Techniques
o Grounding to reconnect and orient to the present,
connect to and anchor body, sensations, all sensory
channels
o Movement – dancing, walking, exercise, shift
position, posture, feet on floor, go for walk, star
jumps…
o Touch/temperature – massage, blanket, pottery, feel
sunlight, warm/cold bath/shower, baking, touch
anchor…
o Auditory – enjoy quiet, listening to music, birdsong,
rain, water, wind rustling leaves, whistling, humming,
singing…
o Vision – look, refocus, gaze around room, photos,
paintings, sunset/sunrise, a fire, movies, cloud
formation, lava lamps…
o Olfactory – smell, scented candles, essential oils,
perfume, baking, flowers, herbal tea….
o Taste – drink, food, chew, crunchy, chewy
o Cognitive – orient in the present, time, focus, name
and describe 3 objects/colours in room

©Christiane Sanderson 2022

 Grounding Skills
Senses Smell – essential oil, herbal tea bag, scent, spices, scented candle
Taste – soothing (honey, sweet tea), stimulting (chilli, lemon)
Sound – music (energising or soothing playlist), birdsong, water
Touch – soft toy, blanket, silk or woolen scarf, ice
Visual – grounding image, photo, painting, screensaver

Body Breathing – blow bubbles, blow up balloon

Body position - favourite blanket, standing up straight, clench and release muscle tension
Body in action – walk, exercise, sport, dance, movement, pull a funny face, yoga, martial arts
Voice – grounding phrase, grounding song, sing, recite a poem, shout, laugh

Mind Refocus attention – identify 3 objects/colours in the room, notice the rustling of leaves, the
feeling of sun on skin, the smell of flowers, sound of birdsong, stress or juggling balls, tangle
toys
Reorient in time – date, time, note differences between today and past
Distraction - count back from 100 in 3’s. suduko, puzzles, colouring books,
Creativity Arts - painting, drawing, pottery, sculpting, play musical instrument, write song, or poem,
Create – baking, cooking, gardening, knitting, buiding
Immersion - grounding hobby

Containment Box or container – in which to place worries, shame, negative thoughts, fears
Balloon- place concerns side balloon
©Christiane and2022
Sanderson let go
Recovery Toolkit

o Use Metaphors
o Anchors and Safe place
o First Aid Kit
o Mood basket, rescue or or
calm bag
o Relaxation Kit
o Cookie Jar
o Treat Jar
o Worry Box
o Shame Box
o Memory Box
o Containment Box
©Christiane Sanderson 2022
 Somatic Safety

o Body awareness - know what feels

safe and what doesn’t
o Body scans
o Identify triggers and the
accompanying bodily sensations
o Identify sources of calm and the
accompanying bodily sensations
o Muscle tensing – clenching and relax
o Physical activity – exercise, sport,
yoga, martial arts
o Playfulness
©Christiane Sanderson 2019
 Somatic Interventions
o Breathing
o Mindfulness
o Hazards – clients experience persistent
unpleasant body sensation which can be
exacerbated by through some
interventions
o Combine interoception with
exteroception
o Breathing hazards – paying attention to
respiration, breathing and heart rate
can be triggering,
o Replicates breathing and bodily
sensations during trauma - rapid
breathing increases oxygen into the
muscles to facilitate flight or fight
o Trauma safe adjustments
 Trauma Safe Adjustments
o Restore power and control –
increase choices
o Reduce rigidity of task
instruction or programme
structure
o Combine intero and
exteroceptions
o Pacing
o Briefer exposure
o Postural positions - sitting or
walking rather than lying down
o Eyes open rather than closed
o Muscle tension or clenching
©Christiane Sanderson 2021
 Phase Two – Processing
o Processing the trauma experiences -
flashbacks, nightmare, unprocessed
memories
o Reappraisal of the unresolved trauma
memories
o Realising and mentalising – legitimise
harm done
o Restore reality – identify self blame,
healthy and unhealthy guilt and shame
o Processing split off feelings – rage, sadness
o Integrate memories into an "adaptive
representation of self, relationships and
the world"
o Work through recurring themes self
blame, guilt, shame, loss, compromised
sexuality, parenting…
o Mourn losses
©Christiane Sanderson 2022
 Phase Three – Integration
o Consolidate skills
o Integrate experiences
o Build meaning and reality
o Reconnect to self, others and
the world - build and re-build
relationships
o Re-engage with community,
life, education, occupational
and vocational choices
o Develop relationships skills
o Reclaim spirituality
o Build resilience
o Authentic Pride
o Compassion
o Post traumatic growth
©Christiane Sanderson 2022
 Short Term Counselling

o Focus on Phase1
o Safety and stabilisation
o Identify resources
o Responsiveness and connection –
optimal closeness and distance
o Pacing - slower is faster
o Resist expectation that trauma will
be resolved in 6-8 sessions
o Partnership links with specialist
organisations
o Consider group work –
psychoeducation, Phase One skills

©Christiane Sanderson 2022

 Right Brain Engagement
o Bottom up and top down processing
o Openness to the experiential world –
play
o Arts and Play Therapies – art,
drawing, sculpture, pottery, clay,
playdoh, masks, sand play, soft toys,
constellations, Matryoshka dolls…
o Drama, Dance and Movement
Therapy – physical activities, exercise
o Ecotherapy, equine therapy…
o Yoga, Tai Chi, martial arts..
o Music, film and books…
o Creating - gardening, cooking,
knitting, building, writing…

©Christiane Sanderson 2022

 The Therapeutic Relationship
o Primary factor in healing and
recovery
o Inclusive, collaborative, non-
hierarchical without ‘othering’
o Attachment focused
o Relational depth
o Dyadic Regulation
o Mutuality
o Empowerment
o ‘Being with’ rather than ‘doing to’
o Regulate closeness and connection
o Repair ruptures
o Compassion focused
o Embodiment
o Promote Post Traumatic Growth
©Christiane Sanderson 2022
 Being a Trauma Wise Practitioner
o Look at trauma through the eyes of the individual
o Aware of power and control dynamics
o Collaborative approach – mutuality, choices
o Genuinely engaged – not what you know but evidence you
care
o Authenticity, transparency, explicitness, responsiveness –
danger of blank screen
o Present and embodied
o Be human to counteract dehumanization
o Consistent, predictable, reliable
o Understand symptoms as protective strategies
o Ability to mentalise - model to client
o Not knowing attitude which is flexible and can tolerate
uncertainty
o Well bounded yet flexible
o Pacing – slower is faster, brake and accelerator
o Inclusive rather than ‘othering’ - ‘we’, ‘and’
o Awareness of the impact of the work – vicarious
traumatisation
o Hope and post-traumatic growth ©Christiane Sanderson 2022
 Practitioner Wellbeing and Self-
Care
o Work – supervision, mentoring, peer
support, CPD, balance trauma work,
regular breaks, set limits and boundaries
o Body – physical health, diet, rest,
relaxation, yoga, martial arts
o Mind - reflection, control and agency,
reading, learning
o Emotion – respect and nurture self, listen
to music, watch films, plays
o Creativity – allow for inspiration, write,
draw, paint, sculpt, music
o Spirituality – beauty, nature, tranquillity,
hope, optimism, passion
o Humour, laughter and play!

©Christiane Sanderson 2022

 Conclusion
o To overcome complex
trauma it is necessary to
integrate mind, body and
brain
o This allows for reconnection
to the body
o Restores ability to live in the
present, vitality and
reconnection to life
o Highlights the resilience of
the human spirit
o Can be transformative for
both client and practitioner
©Christiane Sanderson 2022
 Further Reading

o Boyle, M and Johnstone, L (2020) A Straight

Talking Introduction to the Power Threat
Meaning Framework: An Alternative to
psychiatric Diagnosis PCCS Books. Excellent,
easy to read book on the Power Threat
meaning Framework
o Perry, B and Winfrey, O (2021) What happened
to you: Conversations on Trauma, Resilience
and Healing Bluebird Publishing
o Sanderson, C (2013) Counselling Skills for
Working with Trauma: Healing from Child
Sexual Abuse, Sexual Violence and Domestic
Abuse London, Jessica Kingsley Publishers
o Sanderson, C (2022) The Warrior Within: A
One in Four Handbook to aid recovery for
survivors of childhood sexual abuse and
violence 4th Edition London, One in Four
o Van der Kolk, B (2014) The Body Keeps the
Score London, Penguin

©Christiane Sanderson 2022

 References
o Allen, J.G and Fonagy, P (eds) (2006) Handbook of Mentalisation
Based Treatment Chichester, UK: Wiley
o American Psychiatric Association (2013) The Diagnostic and
Statistical Manual V Washington, APA
o Boon, S, Steele, K and van der Hart, O (2011) Coping with trauma-
related dissociation: Skills training for patients and therapists NY, NY
W.W.Norton
o Cloitre, M., Garvert, D. W., Brewin, C. R., Bryant, R. A., & Maercker, A.
(2013). Evidence for proposed ICD-11 PTSD and complex PTSD: a
latent profile analysis. European Journal of Psychotraumatology, 4(0).
o Cloitre, M., Garvert, D. W., Weiss, B., Carlson, E. B., & Bryant, R. A.
(2014). Distinguishing PTSD, Complex PTSD, and Borderline
Personality Disorder: A latent class analysis. European Journal of
Psychotraumatology, 5(0).
o Cloitre, M., Courtois, C.A., Ford, J.D., Green, B.L., Alexander, P.,
Briere, J., Herman, J.L., Lanius, R., Stolbach, B.C., Spinazzola, J., Van
der Kolk, B.A., Van der Hart, O. (2012). The ISTSS Expert Consensus
Treatment Guidelines for Complex PTSD in Adults
o Courtois, C.A. (2010) Healing the Incest Wound 2nd ed NY, W.W.
Norton
o De Zulueta, F (2006) From Pain to Violence: The Traumatic Roots of
Destructiveness 2nd Chichester, UK: Wiley
o Foa, E., Keane, T., Friedman, M., & Cohen, J. (Eds.). (2009). Effective
treatments for PTSD: Practice guidelines from the International
Society for Traumatic Stress Studies (2nd ed.). New York: Guilford
Press
o Fonagy, P., Gergely, G., Jurist, E.L. and Target, M (2002) Affect
Regulation, Mentalisation and the Development of the Self New York:
Other Press
o Herman, J.L (2001) Trauma and Recovery 2nd edition New York:
Basic Books
©Christiane Sanderson 2022
o Levine, P A (1997) Waking the Tiger Berkeley, CA: North
Atlantic Books
o Ogden, P () Sensorimotor Psychotherapy NY, NY, Norton
o Rothschild, B (2002) The Body Remembers New York: Norton
o Rothschild, B (2017) The Body Remembers II : Revolutionising
Trauma Treatment New York: Norton
o Sanderson, C (2015) Counselling Skills for Working with
Shame London, Jessica Kingsley Publishers
o Sanderson, C (2013) Counselling Skills for Working with
Trauma: Healing from Child Sexual Abuse, Sexual Violence
and Domestic Abuse London, Jessica Kingsley Publishers
o Sanderson, C (2015) Responding to survivors of child sexual
abuse: A pocket guide for professionals, partners, families
and friends London, One in Four
o Sanderson, C (2016) The Warrior Within: A One in Four
Handbook to aid recovery for survivors of childhood sexual
abuse and violence 3rd Edition London, One in Four
o Sanderson, C (2010) Counselling Survivors of Interpersonal
Trauma London Jessica Kingsley Publishers
o Sanderson, C (2006) Counselling Adult Survivors of Child
Sexual Abuse 3rd edition London: Jessica Kingsley Publishers
o Sinason, V (ed) (2002) Attachment, Trauma and Multiplicity:
Working with Dissociative Identity Disorder Hove, UK:
Brunner/Routledge
o Steele, K., Boon, S and Van der Hart, O ( 201) Treating Trauma
Related: A Practical, Integrative Aproach w York, Norton
o Van der Kolk, B (2014) The Body Keeps the Score London,
Penguin
©Christiane Sanderson 2022