Treatment Planning for Complex Trauma

1. Welcome and who we are

0:01As you can see, we will have this training recorded, so if it's something you want to watch back later, or share with a colleague or a friend you think might benefit, we encourage you to do so. We'll make sure everyone who expressed interest has access to it in case you weren't able to be here for the full live portion.

0:24Many of you are familiar faces, so you know us, but a quick introduction for those who don't. My name is Dr. Bridger Falkenstien. Jen and I are two of the owners of Beyond Healing, which is a counseling center here in Springfield, Missouri, with about twenty-two therapists working with a relatively diverse range of demographics, presentations and populations in the southwest Missouri area, and offering virtual support for clients across the state. Within that, we also have the Training Institute, which is what made it possible for all of us to connect today. The Institute offers continuing education and professional development for therapists across the professional lifespan, specializing in EMDR and in Somatic Integration and Processing, a case conceptualization approach we'll share quite a bit about today. And we have the Think Beyond media group, which produces the podcasts and the YouTube channels; pretty much anything content-related gets created through that home.

1:30We've spent fifteen-plus years in clinical practice developing our own clinical wisdom and experience, and all of that comes in to inform the tools we're going to share. Long histories of education and practice, and personal lived experience, show up in it as well.

2. Why complex trauma needs a different plan

2:36As we begin to identify the complex nature of working with complex trauma, we're juggling many things and trying to bring some organization to that, so that we have a clearer clinical picture and can start to formulate a plan with our clients session to session.

3:13For what we're getting into today, the complex trauma focus is different from single-incident trauma. It's different from generalized anxiety or depression. This refers to a type of trauma that has multiple components, from the individual's intrapersonal experience of self all the way through their interpersonal dynamics of relationship and the patterns that are there. This presentation, and the population it represents, needs something that standardized models of psychotherapy often struggle to accommodate, because of the dynamic challenge this population faces in understanding themselves and their identity, their own affect regulation patterns, and the interpersonal dynamics they have so patternistically been involved in. There's such a challenge to change. Lots of good reason to fear change. Lots of difficulty trusting other people. And because of that, there's often a challenge in the therapeutic dynamic itself.

3:49This population, as many of you know, is also incredibly resilient, with an incredibly high functioning capacity, which can also make treatment difficult at times, because the strategies they've used have worked well enough to get them to where they are. There's a hesitancy to change, and the layers keeping everything together are hard to lift sometimes.

4:16So we're really looking at how we help an individual feel that the treatment options we have available, regardless of the modalities we bring in, can identify their suffering in their present symptomology, find the associated origins or memories, and help process.

4:53In working with trauma in general, there often can be a singular focused plan. The felt experience of that plan usually operates like this: I can see a presenting symptom. There's an identified issue. We're able to track that back to the origins and what has perpetuated it over time, and then formulate a clear, single-focused plan around that. Most often, session to session, we're sticking with that plan and seeing gradual progress.

6:30When we're working with complex trauma, the felt experience for me is that I'm trying to juggle multiple pieces at one time and not let any of the balls drop. And yet there's always a new piece. There's always something else we're trying to manage. The complexity of the trauma and the past experiences is so vast that it can be hard to sort out what connects to what. Which experiences or relationship dynamics are influencing which presentations and which symptoms? How are we prioritizing the focus on all of this? For the clinician as well as the client, so much is being held in these complex presentations that we're looking at this more from a network-mapping perspective than a single-focus, single-link process.

6:53In complex trauma, we are juggling the past, present and future all at the same time. With more singular focused work, usually we're addressing the past, tending to the present, and preparing them for the future. With complex trauma, it's cyclical: past, present, and tending to the future at all times. We have to be managing stability and resourcing, helping them navigate present-day functioning, while attempting to heal past traumatic experiences and equipping them for what's coming. There are many moving parts, and a treatment plan built around this network perspective is trying to bring organization to that.

7:15We will never make it simple, because it is complex trauma. The suffering is vast. The pain is deep. The number of traumatic and adverse experiences drastically outweighs the number of resourced moments, the number of times they have been secure and loved and safe and supported. We're working with a very imbalanced history. So we're attempting to bring some organization so that we have clarity and can make formulated decisions about how to move forward with a more complex case.

3. Look beyond the event: before, during, after

8:00The cyclical nature of this presentation warrants a way of approaching the case that we talk about as before, during and after. We're looking beyond the known traumas. This is an aspect of working with this population that can feel the most daunting in session: when you start to ask about the memories, if you're working with EMDR and doing a treatment history timeline or history-taking phase, you start to see pile after pile of some pretty terrible things, and patterns that lingered and were recapitulated in later relationships.

8:40So one of the first moves this way of working requires is a means of contextualizing what actually happened as a during. That's an instance of what we typically think of as the traumatic experience, often several in the case of complex trauma, across development, each connected to and shaping the others. But the task is to see the before and the after of the during, because in many cases that is where the locking-in of the hypervigilance, or the symptoms and strategies created in the during, actually holds on tightest.

9:22The before is what set the stage: the relationships, the needs they had, the absences, and how all of that shaped how the system learned to brace for what came next. For so many people living with complex trauma, there's a series of stories, breadcrumbs, that highlight the lack of stability, security, attunement, consistency and connection dating back to their earliest memories. They didn't have a reference for a safe person or a calm place or a protective, nurturing figure. It's memory after memory of doubt and question and concern and instability.

10:12The after often highlights the effect of those absences. In the aftermath of what happened to them, there was not a community to return to, to repair or to attune, to actually feel felt and embraced in what happened. "I couldn't talk about it," or "I had to act as if nothing happened to me." How others responded, what the person was told, what they concluded about themselves and their body, as well as the image of other people and what threat they represent. With this population, because of how many experiences they've had and how fragile the attachment environment was before, there's a very difficult time recovering from anything that happened. Strategy, in many cases, is the only way they learned to survive, and those strategies have to be maintained across time.

11:04So complex trauma rarely comes down to one event. All of you working with this population know this. It's not just the power or distress found in one event. It's many, and connected experiences affect one another. So we plan for the network. Not every case has a single root memory. We map what came before, during and after.

11:28What we're finding is that a core wound is a cluster of many experiences that represent the same injury, the same pain point. When we begin working with stories and memories and experiences, if our focus is limited to what happens in one event, we're missing the context that set the stage for it and the way they made sense of it, as well as everything folded into their understanding of themselves and the world afterward. Even though some trauma modalities focus on a particular event, the complex trauma perspective needs to hold the before, during and after. That event becomes a representation, a symbol of the larger picture, rather than the exact thing we're working on. We can work with a singular event and still make progress with EMDR or TF-CBT or another trauma approach. But in our treatment planning, we have to understand that it's part of a network, and our approach to conceptualizing and working with it is from the full network rather than the single event.

4. Three lenses: relationship, body, memory

13:01Some of you may be familiar with this image from our case conceptualization training, Somatic Integration and Processing. These are three lenses, three theoretical orientations we bring together to formulate a holistic perspective of a case: their history, their present-day patterns and functioning. We're looking at relationship, body and memory as different lenses, and as a way of understanding that before, during and after. As we scope out the full picture from a complex trauma perspective, we want to be looking for patterns, information, messaging and strategies that unfolded through relationship, body and memory.

13:55In relationship, we're looking at attachment and neurodevelopment: the relational patterns and relational conditioning that have occurred throughout development, and how they're playing out in present-day relationships, including the therapeutic relationship. We're looking at the relational strategies that developed to establish safe enough and secure enough, and to get needs met.

14:21From the body perspective, we're looking at somatic psychology. We're tracking patterns of distress, activation, co-regulation and regulation, and seeing how those are held in the body through patterns of sensation, activation, movement and nonverbal communication, letting the body be a source of wisdom and an avenue for communicating some of these stories.

14:55The third lens is memory. Here we're looking at the AIP model and memory reconsolidation, where it is through unprocessed past experiences that we continue to encounter present-day patterns of activation and maladaptive responses, and it's through healing and processing those past experiences that we find relief from present-day symptoms. All of that with the more complex lens, not the singular focus.

15:28With this Venn diagram in mind, the rest of our time together is going to be about a five-component process: theme, map, sequence, pendulate, integrate. This is maybe as standardized as we'll get with this population. In general, this is the sequence we progress through.

5. Step 1: Identify the theme

15:54We start with step one, identifying the theme, and we look through each of the three lenses as we do this. It doesn't have to go in this sequence, from I am, to because, to therefore I must, and then the ask. But this is how we try to structure some of our first explorations with these individuals: trying to understand what the person has come to believe about who they are because of how their life has gone.

16:29The "I am" statements give us a window into their self-concept. Through the relationship sphere, this is where we get into attachment styles, or internal working models, which talk about the "I am" of self and the "you are" of the other. So we start to explore, even at a high level, the ways a client talks about themselves or their relationships, the language they use, the affect in their voice, the type of memories they choose to share, the people they talk about and the ones they don't. This is some of what created that impression of self: through what happened to me, I learned to see myself and the world this way.

17:21Then we move into "because": because of what has happened, in the instance of my identity being shaped through my attachment environment, the relational and lived experience has made that believable and necessary. This starts to create an expectation, really a prediction, of what these moments will include.

17:53Because of that, we move into the strategy. As a person develops their own sense of "here's who I am, based on how my world is treating me and what I anticipate a situation will include," they've got to show up with a strategy that can keep them safe, keep them alive. For so many with complex trauma, there's a range of highly dismissive and suppressive strategies that create a blank slate: I'm unmovable. Or there's the other side of the spectrum, high volatility and high affect. You often see pendulation between a blank-slate mask and something volatile, unpredictable, chaotic. Either way, it's a strategy looking for some feedback of success and ease. Does this make it easier for me to anticipate what the next moment might include? Am I more safe? Am I less safe? Where is the threat, and what does it look like?

19:15The final piece is the ask: what does it protect? Once we can get some language around the strategy, whether it's hypervigilance or dissociation or lack of motivation, changing jobs or staying in the same job, staying in the same relationship or hopping from relationship to relationship, we look at what it protects. What is the layer underneath the strategy that's loud, or that is consistent across time in their life? What does the strategy still accomplish now, even at a cost?

19:33With more single-focused trauma, we often look at an experience and identify a negative cognition or negative self-belief associated with that memory. With complex trauma, we're looking at identity structures. It's more than "what do I believe about myself in this experience." It's "this experience is just another example that proves what I already know to be true about me." Those are very strong felt differences in the therapy room for the client. It's not just a cognition we're shifting. It's identity. Through multiple experiences, through recurring exposure to not having enough or being affected negatively in some way, I've come to understand myself through those experiences.

20:27So the "I am" piece may use a similar sequence of words, like "I am unlovable," which can look like a single-focus negative cognition. But here it means it's not one event that caused me to question my lovability. It's a full sequence of repetitive occurrences that have snowballed and built that identity, where it's not that I question whether I'm lovable. It's that I know that I'm not. And what I'm hoping to do in treatment is begin to question that. Is it possible to be lovable?

21:07Finding these themes, and having our treatment oriented around them, is a really supportive way to start organizing the symptoms that show up, the stories they tell, the goals they're setting, the interactions in our relationship. The theme approach gives us organization and structure. Even though it's a simple sentence, "I am, because, therefore I must" summarizes what is really held as an identity structure.

21:48What I have seen is that we enter at different points of this sentence. When we're developing a theme, we don't get it in this exact order: what do you feel is true about yourself, what taught you to be that way, what strategy are you using? Sometimes they come in telling us the strategies. "I'm constantly anxious." "I'm constantly scanning my environment, looking for the next worst thing that could happen." "I'm always preparing for the next person to leave me. I'll be alone in the end." We find these symptoms coming up, and if we can look at them as strategies the nervous system built, behavior that has a reason, a purpose, an intention, and is there to protect them, we can work backwards. What has shown them in their life that they need that? What experiences told them you're better off if you anticipate bad things, so you're not caught off guard, so you can prepare for them? Then we can identify the core belief they hold about themselves, and some of the early experiences and messages that kept perpetuating this protective mechanism.

23:07So we may learn strategies first. We may get the negative beliefs or identity structures first. We may see what it's protecting and how it's showing up now. But to really formulate a theme, which is the foundation, is to ask: do I have an understanding of each point in this statement, so that I can articulate the theme, and then we can begin to build our plan from here.

23:41Thinking about this with a client I've been seeing for several years: this belief is so protected and insulated. "I am unlovable, because I am disgusting or fundamentally evil, therefore I must be perfect in everything that I do." When you really start to peel back the layers underneath each piece, it doesn't go back to one high-SUD memory, "here's where I was assaulted," or "here's this terrible accident where nobody was there for me." It's filled with hundreds and thousands of little memories. We talk about them as having the stamp of proof on them: "I am unlovable, because my mom was never there for me. She always wanted me to be more than I ever was, and different than I ever was. She would deny that I was struggling with things related to my neurodivergence, and create this mask for me." Then there were bullying experiences and assault experiences he felt he couldn't share with his parents because of that. The "disgusting or fundamentally evil" part has so many layers of the church, and dad, and his sister, perpetually making him feel "I'm just not the same as other people, and it must be because I'm evil, and that's why I'm not going to get into heaven, that's why I'm never going to be happy." Therefore I have to be perfect, because the only place he ever got any validation or connection was through performance and accomplishment. That insulated a little box he had to stay in for the rest of his life. Now, in his mid-fifties, he's starting to feel like his life is in shambles, because he can't find the feeling of embrace he's been looking for. "My marriage is falling apart because I'm disgusting and she doesn't love me anymore." It insulates itself.

25:54So once we identify the theme, that's where we start talking about the map. The theme is going to hold, especially the more collaborative the language can be, where we put that sentence together as a team in the therapy room. That's the first of many breadcrumb trails to follow. If we had three or four hours, we'd spend quite a bit more time in each of these, because there's so much there. But that really is the foundation for the later pieces.

6. Step 2: Build the treatment map

26:32With the theme as our foundation, our center, we're then looking at all the pieces associated with or connected to it. How is it showing up, how is it playing out in their world, what has shaped it over time, what cost are they paying now? In the example just given, the cost is "my life feels like it's in shambles, I feel very alone, I feel very unseen." How is it showing up in the present, as well as what created and shaped it in the past?

27:05With no other strategy. That's another aspect of this presentation that can feel so hopeless: the strategy I'm using today is the best I could find throughout my life, and when it starts to fail, I don't have any other options. I just have to keep hitting the same button. For him, it's perfection. "I've got to be perfect. Why am I not perfect enough? Why do people still not embrace me the way I want, or give me the safety I've always been looking for? There's no other option, so I just have to keep being perfect." It's like being trapped in the strategy of the theme.

27:46As we navigate therapy with complex trauma, as you know, anything can come up. Very rarely do we make a plan one session and then the next session comes in and we follow it perfectly. There's the new crisis, the new symptom. We're always juggling. But we look at everything we encounter and ask how it connects back to the theme, or, if we're tracking more than one theme, to one or the other.

28:16If they're telling us different stories of the past, we're asking whether this is another representation of the theme. Does it show another way the strategy was used and perpetuated? Does it show another experience that was proof for the negative belief? We're also tracking what experiences were missing. What did this individual need and not get that further solidified the theme? Did they need someone to help them make sense of all the adverse things happening to them? Did they need co-regulation, nurture, care, control, stability? What were the missing ingredients that could have allowed more flexibility and variation to the theme, where instead, because of those missing elements, it became more concrete and rigid?

29:18We're looking at current patterns and symptoms: what's playing out present day, and specifically what's playing out in the therapeutic relationship. Are there relational patterns, presentations, strategies, and how do they connect to this theme? The way they participate in therapy, the way they engage with us, what they anticipate and predict in our process.

29:51We're looking at relational context, past and present: the therapeutic relationship as well as the other relationships in their life, and how they're playing those out. Are these reiterations of the same pattern? Are these attempts to break out of the pattern and do it differently?

30:16With all of that, we're looking at the more painful or adverse experiences that have contributed, while holding space and priority for the strengths and resources that emerge through this lens. We'll get into it with pendulation, but a big part of complex trauma work is that it can't be all distress-oriented work. We have to balance the resource-oriented work to keep the process tolerable for the client.

30:52That can be one of the most difficult parts of this presentation, because the "because" of the theme, the reasons behind the "I am," and the ruminative reality of that idea, is so insulated so much of the time that helping a client see they have a genuine strength or resource can itself be a heavy lift. Thinking again about the man I was describing: the theme and narrative plays through his head so constantly that even acknowledging "you've built businesses, you've built all of these things," and not whether they were successful, which gets into the perfection, but just the nature of having the skills and mastery that you have, the choices and agency and creativity, the goodness in how you show up and love people, there are aspects of that which disconfirm the theme. But even to acknowledge it, it immediately gets blended up into "well, I can disprove that." His strategy is very intellectual. It takes the disconfirmation apart and makes it fit the theme again.

7. Step 3: Sequence by readiness and distress

33:30So we're looking at pacing. When we identify the theme and help the client understand this isn't going to come back to one memory, that this is a way you've experienced your life and what happened to you, then working through the theme and the map, once we have some focuses in place, is where we start to titrate the work.

33:31We don't necessarily begin with the heaviest trauma. We segment it: lower distress, one to four on a SUD scale; moderate distress, five to seven; higher distress, eight to ten. Sometimes I talk about this as three doors. Behind each door are memories that fit that distress level. That helps us get traction on the lower-distress memories, which then turn into resources for the higher-distress memories later.

33:32Lower distress: theme-linked memories the client can approach without being overwhelmed. Often a good place to build tolerance and trust. We're looking at the therapeutic relationship and the disconfirming experiences we can create by processing a lower-distress memory, and bringing that resource into higher-distress memories later.

33:58Moderate distress, five to seven: approached as capacity grows. In our experience, these sometimes come down as the lower-band work proceeds. It's a stacking down I see with my clients. As we start doing the one-to-four memories with EMDR, or even just processing them relationally, what previously might have been higher distress starts to slide into lower distress. That's a great sign, a tremendous indicator that we have momentum. Most of the time I find clients then come in the next session with the crisis of the week that obliterates our focus, and it's tough to keep the momentum going. But this is a really good way to pace the work, especially with an emphasis on resourcing what you can, knowing some of the strategies might be defensive toward that.

34:58Higher distress: memories approached from a resourced state, when the client is ready and chooses to. Never forced as proof of progress. This is our bias, to pace it this way. Many clinicians still choose to go high distress first and continue from there. For us, we're looking at pacing: lower distress first, build momentum into moderate distress, keep resourcing along the way.

35:26A lot of clients come in with an early motivation and urgency toward the higher-distress place, whether it's the most catastrophic thing in their life right now, "I'm in the middle of a divorce," "I'm at risk of my kids being taken into custody," "a family member just died." There's a main issue their system is desperate to address and get relief from. If it feels necessary to address those first or earlier on, then we have to hold the fourth point, pendulation, as a high priority. There are ways to move into higher-distress experiences earlier, but we have to find a counterbalance.

36:13Pendulation will be key. If our work stays in high distress session after session, the client's nervous system, even if their will and desire is to do it, gets exhausted. They are holding so much day to day, from their present, from their past, from everything they're anticipating in the future, that their tolerance and capacity to add on is only so much. Often in complex trauma, therapy is seen as a retreat away from the intensity of distress, and it's hard to find motivation to walk in and say "let's make it even bigger, let's go in depth on some of the hardest things." Instead they're looking for "maybe this is a place I can find relief." "Can I feel connected? Can I get some tools? Can you give me something to make it feel a little better?" rather than building up momentum to say "I'm ready to go into something really intense that's been boxed away for a while."

37:33So starting in lower distress and progressing doesn't mean ignoring what's relevant to them right now. It means balancing the intensity, finding where we can build up to that, and where we can balance it with pendulation.

8. Step 4: Pendulate, rather than push straight through

37:53In my experience, this is one of the most helpful aspects: doing the pendulation work from "let's be present with confronting the distress and discomfort you feel now," especially in present-day patterns. For so many clients this can be one of the most fruitful ways into the breadcrumb trail of the map and the theme networks. We very much attune to the distress of the now, but we also build in space for resourcing, for the capacity to have disconfirming experiences and let them in.

38:52This back-and-forth oscillation, this pendulation, is what weaves the treatment plan together. If there's so much emphasis on high distress that we can't get any relief, this is where, in my experience, the therapeutic relationship starts to fatigue, and we slip into ruts where every session is just really hard. Not that we're trying to make it sunshine and rainbows by switching it up on the client. But we've got to find a way to emphasize progress and resource and ability as much as we focus on what is creating the distress.

39:50The same theme we've identified holds both. We move between them, across and within sessions, as capacity, safety and goals allow. Looking at the present-day experience can help us stay out of the weeds of chasing every past experience, and keep us focused on the distress we're experiencing right now, and how to understand that as a pattern that goes back in time, faced many times over. I talk about it with clients as baby steps: baby steps toward the belief that maybe change is possible, and maybe we can try a couple of different things, even if we just do it here and now, with us, first. To start to name discomfort and how bad something hurts, rather than mask it. To name "I'd rather sabotage this than let it create the fear that you're going to leave me." Trying to make that discussable, approachable together, can be one of the first and most helpful aspects of working with this population.

40:49What often gets missed with complex trauma is that pendulation is necessary as much on the resource side as on the distress side. If we think about complex trauma, the window of tolerance is very narrow. What degree of affect, distress or resource or connection, can my system tolerate before I have to come in with a strategy to turn it down, numb it, protect it in some way? In nervous systems that have experienced complex trauma, that window is narrow, and pendulation is a tactic for expanding tolerance. Not just tolerance of distress, but tolerance of resource. Tolerance of connection. Tolerance of adaptive relationship.

41:47So pendulation isn't a step we do once. It's constant. If we're starting therapy early on, and through the lens of EMDR resourcing is often where we begin, what resourced experience can this individual tolerate? I can't jump into a deep, meaningful nurturing-figure moment where they're experiencing unconditional love and connection. That's not tolerable in a highly traumatized nervous system. They have learned that's not possible, not real, not something I can trust. They've learned all these reasons to discredit the extremes on either end. So pendulation asks: can we move into small, tiny moments, on both sides? We can't jump into total safety in a blissful, calm place where nothing bad ever happens. Their systems will shut that down right away and not even connect to it. But can we start with neutrality? Can we start with small experiences on either side, building capacity for the higher-distress experiences as well as for the more meaningful experiences that hold depth and connection?

9. Step 5: Integrate into present-day life

42:46Step five is integration, and again we look through the lenses of the Venn diagram. Through relationships: as treatment progresses and we get traction through the segmented distress scale, through pendulation into present-day experience, are there new responses with real people out in the world that we can name and validate and bring back into the therapy room? Even if it's just between the two of us, noticing a different affect than was there before, can we name it and install it as a resource?

43:26The body sphere: the new felt sense outside the room. Can I notice more feeling, or more capacity for feeling, as I start taking the layers off the strategies?

44:06The memory sphere: new experiences updating old expectations. This can be tough to pull out of how fast sessions go, and how immediate things in session are, or how slow things feel. How do we pick up the disconfirming experiences, the new experiences, that have implications for the past experiences and the logic that contributed to the theme?

44:46Then daily life: small steps the client chooses. Are there baby steps we can see and name? This is one of the skittish elements with this population. When we start acknowledging that change is happening, they can feel insecure, and a walling-up can happen. So, again, pendulation, even in that. Can we acknowledge that this might feel a little different, that the same ruminative expectations aren't catastrophizing the future quite the same way? Can we bring that in each session: where did this show up in your week, and what is one next step? It's a very practical, grounding rhythm to get into with the client. How did this shift, even a little, in how you encountered this week, and how can we take that into an intentional relationship moving forward?

45:26Integration is not the final phase. It starts in the first session, and it's where progress becomes visible. It's not linear. We're always checking in on the theme: how real and true does that feel now? What does that mean for the map? The sequence can change. Pendulation becomes more informed. What we're integrating into daily life should reflect that progress too.

46:06Progress for our clients has to be recognized and felt in their present-day lives. It can't be only through reflection on whether the SUD decreased, or whether I completed the task of that memory. It has to be realized present day, to maintain motivation to do this hard work. Clients with complex trauma are holding so much already that if there isn't a clear link from whatever we're doing in the past to a felt difference today, the motivation starts to decrease, and we see burnout in the therapy process. Finding the courage to feel the hard feeling again will not stay motivating unless there is some benefit in their present-day lives.

46:46So even if past-focused work occupies a big portion of the session, with complex trauma the present-day focused work is just as important. The most optimal experience: as we do the past, can we connect it to the present and have them become aware of how that past piece is showing up in everyday living? The lenses help them notice: relationships, body, memory. And then the challenge: can you take one small step with this awareness? Do you now have a choice to challenge that theme in some way, to take new action, to not engage in the strategy, to participate in something that might build a positive feeling? We're constantly balancing both.

10. The composite case: Cora

47:53Content note, as given in the workshop: this is a composite case published by Beyond Healing Institute. It includes childhood sexual abuse, dissociation and a high-control religious upbringing. Take it at your own pace.

48:26We're going to share a case vignette to guide the remainder of the workshop. This is a case that represents many clients. It's a composite, featuring recurring aspects from our clinical experience, and one a consultee could bring to a consultation session. Our invitation is to sit back and notice what comes up, from your own clinical experience in the room, and especially notice the feelings you have as they come up.

48:30The pseudonym we're using is Cora. Cora is in her late twenties. She works from home in a mid-sized city, and wrote "anxiety and relationship stuff" on the intake form. When she comes in she sits still. She is quiet, articulate, a little formal, careful with her words. Eye contact is intermittent and you can feel the effort in it. She was diagnosed as autistic in her mid-twenties, after a long time of masking well enough that no one had thought to check. Though officially diagnosed, she never leads with that. She leads with the mask she has learned to wear all those years.

49:16She has ended two long-term relationships in the last four years, both times before her partner could. She cannot tell whether that was protection or self-sabotage, and she has asked herself that question often enough that it no longer helps. It just continues to ruminate. With her most recent partner, sex became something she performed, and then something she disappeared from. She did not know how to say that at the time, and she is not sure she knows how to say it now.

49:55Mornings are a negotiation with work she used to like. She cannot make herself open the laptop until the guilt gets loud enough, and some days that isn't enough and she withdraws from it altogether. She has not left the apartment for anything but groceries in three weeks. Sleep is broken. Appetite is sparse. She is not using substances. She is not actively suicidal. She is, in her own accounting, failing at a life that looks manageable from the outside.

50:29Over time she shares what's underneath the present exhaustion and burnout. She was raised inside a high-control religious tradition, where purity culture was installed from the top down. Obedience was framed as love. Questioning was framed as danger, to her and to the family's standing. She left her family in her early twenties. The family is intact, for the most part, at least on the surface, where they're warm and inviting. But the things that happened to her are not spoken of. She goes home for holidays and dissociates on the drive back every time.

51:09From about age nine to about age twelve, she was sexually abused by a male family member. In her teens she told her mother. She was told the family would not survive the accusation, and that she must have misunderstood what was really going on. She did not tell anyone again until this therapy.

51:29In session, when something gets too big, in her words, she goes somewhere else. Sometimes she is watching the room from the ceiling. Sometimes her voice keeps talking and she is not in it. She can describe this with some precision, which is easy to mistake for embodied awareness.

51:48Preparation, in the EMDR sense, went well. She could build a container. She could find a calm place. She rated her distress honestly, or at least what she was willing to say. The trouble started when the work moved toward the abuse memories. She got quieter, further away, more articulate. Her voice went flat and precise. She described a scene she had just said she had never spoken aloud, and she rated it a two out of ten on a distress scale. The therapist's own body registered something closer to a nine. Between sessions she stopped opening the laptop entirely. She canceled twice. She came back apologetic and composed, and she said she thought she should probably just push through.

52:42The therapist has a series of choices to make, and none of them feel right. Keep going. Go back to stabilization. Switch approaches. Wonder whether she is the wrong therapist for the case. What she does not yet have is a way of seeing the case.

52:57That's Cora.

11. Reading the case through the three lenses

53:11This case is illustrative of some of the dynamics we've been talking about, especially the element of talking about something she never told anyone, rating it a two, while the energy in the room was much more distressed than that. It's through the mask she learned to wear. We'd love to hear what's coming up. Put it in the chat if you have space to.

54:02Complex trauma cases often create our own points of activation: fears, hesitation, urgency, hope. Some of that is named in Cora's case, where the therapist is wondering, should I refer her out? Should I recognize my own distress and speak to it? Should we just follow what she's saying and push through? There are so many points of contemplation, and the more complex the case, the more layered it is, the more we're sorting out our own felt experience. Part of a treatment planning process is holding those moments of self-reflection: what is showing up for me related to the point we're at in this case, or this part of the story? What's my own felt experience of the pattern playing out in the room and in the therapeutic relationship?

54:59Sometimes that is where our tracking of the theme starts. We may not have known the theme yet. We may have been focused on a different theme. It's when we hit those stuck points, those pain points, those moments of incongruence where something is not adding up, that we can start saying: what's the theme here? Is this a pattern worth tracking? Could there be some strategy here? That's what we're going to break down in Cora's case through the lenses.

55:37From the chat: a few are commenting on the SUD difference of two and nine. "Sounds like she has a really protective system, and for good reason." Others are sharing that they have clients like this, and the urgency they feel to jump in and try to help, that frantic feeling. Also comments about realizing their own subconscious feelings or patterns coming up.

56:09One of the aspects this case was designed to highlight is a dynamic I find is often present in complex trauma, where the client is at a divide: "I've learned that I can't be transparent or authentic in expressing what's actually coming up in me and what I'm feeling, so I'm calibrating the mask to suit the dynamic I'm in." The spectrum of strategies can differ. Some present more polished, as in Cora's case, where there's been messaging throughout life that "I've got to put it away." Others have learned to create more chaos in the room, to keep other people on their heels, not knowing what's really going on. Either way, it's that disconnect between what is actually happening in me, what I want but am terrified to ask for or don't believe is possible, and the mask I've learned to wear to find some control over what's going to happen to me in my environment.

57:36Looking through the three lenses, we won't go through the specific language of the theme, because that's something we really encourage to be created collaboratively. We want their language, their naming of that sentence.

57:52Through the lens of relationship, we're exploring what was learned. A possible lesson Cora learned: love was conditional on not being a problem, not creating disruption, not having too many needs or identifying conflict. Telling the truth cost her people. If I'm to tell my true experience, or honor what my experience was, it may risk my relationships. The flat, precise voice may be that lesson at work. In the part of the vignette where she's naming a potentially highly distressing moment she's never told before, with flat affect, a precise voice, not a lot of emotional expression, and explicitly identifying it as a two, that may be a symbol of that same lesson: in order to tell my true experience, it may cost me relationship.

59:02From the body perspective, her nervous system may already carry a high sensory load, and dissociating when activation gets big may be part of the same strategy playing out in her nervous system. When the affect or intensity gets overwhelming, and it can't be expressed honestly in my environment, reducing it or dissociating away from it is a mechanism of the same theme. That's what kept her safe and allowed her to navigate relationships.

59:38The memories are held as what happened, as well as what happens when she shares her experience. This is not just the traumatic experience of the assault itself. It's the story around it: how did the people around me respond, what sense did they make of it, how did it change my circumstances after? The event, plus the before, during and after. Approaching the first without the second may confirm that speaking it makes it worse. For her to go straight into "okay, we're going to push through and address that" is working against what was learned, or rather, joining what was learned: "what happens when I tell my story?" Whereas through tracking the strategy and noticing the theme, the therapeutic relationship can come in with more intentionality, and the process of therapy can help heal and fill in the gaps of what was missing while we address the actual experiences.

1:01:00Some other comments are highlighting an aspect of this work that we'll talk about in depth in a forthcoming workshop: to sit with this population, there is real importance in doing our own work to understand what kind of regulation we bring into the room, and what our own compass is picking up on. The whiplash that can happen in these sessions can confuse what is mine and what's the client's, what's in the room and what's not. It's not to say you should only trust your body as the therapist and tell the client they're masking or not seeing reality. Not at all. It's inviting the therapeutic relationship to attune to what's beneath the strategy, and to help the client feel safe enough to try naming authentic expression before it gets edited and filtered by the mask. That takes a lot of ethical, intentional work on the therapist's part to understand what's going on in me versus what's happening in the room and in my client.

12. Connecting the presenting concerns to one theme

1:02:22When we look at connecting to the present concern, the blue box on the slide is an example of a theme as we might create it to illustrate with Cora. This is built together. We're trying to find language that is collaborative. This isn't us giving them a sentence or a paragraph. It's trying to find the most representative and validating language for what's really going on. Something like this is what I would strive for:

1:02:50"When I made myself small enough not to be a problem, I got to keep the people I needed. When I told the truth about my body or my experience, I lost them. My body learned to survive by disappearing before anyone could send me away. And now it disappears from the apartment, from my partners, from my work, and from me."

1:03:11There's this strand of trying to tolerate dysregulated affect and make sense of something terrifying in a world that didn't attune to her, to now: I keep myself hidden and small in an effort to preserve some semblance of attachment, some semblance of safety and regulation capacity.

1:05:06Then we look at the things that perpetuate, and are also results of, some of those wounds created early in life. The apartment, the only refuge she has, the place she maybe hates and loves: "I don't want to leave this space, but I also know I'm not getting the connection I want, and I'm not doing the things I want to do, but it's the only safety I know." Same with the remote job: "my only safety is at a distance, where I can disconnect and immediately have control over my participation." The preemptive endings. The dissociation during physical intimacy, not having language for what boundaries and consent and even desire look like in herself.

1:06:01The disclosure memory, where she told her mom and her mom said the family wouldn't survive the accusation and she must have misunderstood, is one memory we have. It is not the only one. The pattern of masking and making herself small likely showed up in many instances of her life, and there's much more behind the strategy than that disclosure. And yet it offers a lens for the present therapeutic relationship. What does it mean that the last time she told this story, her mom essentially rejected and dismissed it? What does that mean for us right now? How does it characterize how Cora reacted: "I rated it a two, maybe because it's buried and I don't really want to share how distressing it is." And then coming back the next session and saying "even though I canceled, I'm here, and I think we should just push through." This is not certainty. It's curiosity. But are there bids for "I want you to still keep me around"? "I know I said the hard thing last time. I think we should just keep going. Please don't reject me, even though I just told you a really terrible thing, when the last person I told rejected me." Is there space for us, as the therapeutic dyad, to validate the fear behind the rejection sensitivity? To name that it's okay to be honest about the pain you feel, that you don't have to have an answer or justification for it, that you can just have the feeling and I can be with you in it? Is there any little foot in the door we can get to that place?

13. Resourcing the theme and choosing an entry point

1:06:56Looking at resourcing, to support the pendulation of resource-focused work that balances the distress-focused work. In resourcing for complex trauma, we can have generalized, standard resources, but really we're looking to craft them uniquely for this theme. What were the experiences that were lacking, the needed relational, emotional, developmental experiences? And what experiences would help disconfirm the negative self-belief, collecting evidence, even in the smallest examples, that maybe that belief isn't so rigidly true and generalizable, and we can add some flexibility to it?

1:07:38Some examples from Cora's case. An adult moment where she said a true thing and was believed, even in a small way. Was there a time she expressed a truth about her experience and the person receiving it believed her, supported her, didn't abandon her? A friend, a coworker, a book that named her experience. This gets more removed from the courageous action of telling part of my own experience: I witness it in someone else, someone modeling naming their experience and that being valuable and not worth being rejected for. Therapy itself is a very rich environment for disconfirming experiences. What can we act out in the therapeutic relationship, intentionally, to create that disconfirmation? That's part of the pendulation process, creating meaningful adaptive moments in the relationship. We can also create constructed figures, visualized representations that stand for getting those needs met.

1:09:03In Cora's case, there's layering. In the way Cora talked about it, there were two obvious "here's where the big target might be" moments: the age nine to twelve sexual abuse, and the fact that she was dismissed and rejected when she tried to disclose to someone she thought was safe. Those are two big-T targets that might be wrapped in the insulation, guarded by the strategies she learned to develop and maintain as they occurred. The network behind them is where we can find little breadcrumbs to get into the sequence of segmented distress, looking for foot-in-the-door moments to get to where that theme really began.

1:09:59The first idea: the moment before she opens her laptop. Is there a time your body felt like moving would cost you something you couldn't afford? These little moments of "I've got to do this thing, I don't want to, I don't know what else to do, so I'm just going to do it, or completely withdraw." That moment itself might be something we can make a target of, and find resources to help her feel more agency in choosing.

1:10:27Another: the doorknob she does not turn. Can you recall a time your body knew being seen was not safe? There might be the big connection to the assault memory, but I would imagine many instances of the fear of being perceived or watched, or not having autonomy and agency in how her body was encountered.

1:10:55The going away in intimacy. What is a time your body learned that going away was the way to stay? There might be obvious links back to the trauma of the assault, and we'll need to pay attention to how the room handles that type of inquiry. But alongside the big-T trauma there are lots of little ones: my body feeling like the only way I can make it through is to disappear from myself. When she talks about "I hear myself talking" or "I see the moment from the ceiling," what are those moments like? If we can pull them out and focus on them individually, could those be some of the breakthrough opportunities for resourcing and reprocessing?

1:11:37Her voice going flat while telling the truth. Can you remember a time you said a true thing and your body had to make it safe? Looking for validation toward the big memory, but also the little breadcrumb trails we could pursue to find momentum in resourcing as we go.

1:11:59Across all of these: an accessible, tolerable starting point, chosen together. With complex trauma, and in general with people, but especially with this population, consent and mutuality and the ability to collaborate on the direction of care is essential.

1:12:19A question from the chat: Is there a way of collecting history and identifying targets from this theme approach, rather than a comprehensive history-taking or trauma timeline?

1:12:33Absolutely. In our practice, with complex trauma, we approach from the beginning with a thematic approach. Can we identify the most urgent, pressing present-day issues and symptoms, reconceptualize them as strategies, and see that those strategies now have a cost in their world? The cost is what they're coming in with: "I can't get along with my partner," "I feel left alone," "I have no social connections." What's the strategy creating those outcomes, and can we work backwards to the theme and develop our treatment planning from that?

1:13:18With complex trauma, doing a comprehensive history-taking and target identification can feel exhausting, exposing and highly activating, and likely we won't get to most of it for a really long time, if ever. It can be almost pointless to take them through that process. Many individuals with complex trauma have been in a lot of therapy or treatment and are desensitized to it. They'll narrate everything that's happened as a list, and that works against what we're trying to do in therapy. They want to slow it down, make it intentional, organized and purposeful, and then go deeper, not skirt across the surface giving all the details without the emotion. Great question.

14. Putting the plan into practice

1:14:16Connecting this to Cora, we're giving a hypothetical sketch for the case: individualized, and revised as we learn. This is common with complex trauma. You create a plan, and within a week or two it's changed. Then you create a new one, and within a week or two it's changed again. Treatment planning has to be adaptive, responsive and individualized. If we attempt standardization and rigidity in how we approach treatment in these cases, we end up marginalizing the client, creating the necessity for strategy to come in, and therapy becomes a place where we act out healing rather than realistically experience it.

1:15:06So we watch for what is active now: the present-day strategy, the present-day symptom pattern, what's happening in their life today. We can track this through present-day occurrences, resource development, trauma processing, or both. In Cora's case, what's present day is speaking a true thing and being masked. The goal we're aiming for: can we have an expression of her true experience, and have it met by another?

1:15:46Then we move into understanding what taught that strategy, where it was learned as a necessity for connection, survival, or getting needs met.

1:15:56And all along, through the work, we bring each step into her present-day living. Not only are we looking at the past, at the core experiences that taught and perpetuated the strategy, but how are they showing up today, and how is each small step we take showing up as a change, a difference, a new effort, a new skill in present-day living?

15. The worksheet walkthrough

1:16:32One of the things we wanted to share is a treatment planning worksheet. I'll put it in the chat for you to download. It will also be included with the slides and the recording when we send them to you. It's designed to implement the tools we've recommended in this workshop. It's a PDF you can print, or convert to a Word document and fill out on your tablet or computer. There's space for the presenting issue and the client's goal, and then all the steps we've been talking about: the theme, the map, the sequence for readiness and distress, what those targets might be. Then you use your modality of choice to do the work.

1:16:51Mapping the network: these are placeholders to begin identifying the before, during and after. The missing experiences section gives me some orientation: what do I need to help create, or be watching for, or encourage them to develop in relationships inside and outside of therapy? That's one of the things my system is most oriented to, seeing what they needed and never got, and being intentional about folding it in no matter what we do. Is it voice and choice? Nurturance and care? Control? I can create moments that allow them to have that felt experience in the therapeutic relationship and in the process of therapy.

1:17:09One note on sequencing the events: in complex trauma you could probably come up with fifty low-distress experiences and fifty moderate, there are so many representations. We're looking for the ones that are most symbolic of the network and approachable. We don't have to hit every experience, but we need enough representations. We don't want to create an overwhelming list where there's exhaustion or defeat before we even get there. Keep it focused and specific, choose representations in each category, and see what begins to shift as we approach them.

1:17:28For the final piece, pendulation and integration aren't things with a to-do to track in treatment planning, but they're placeholders we hold. We're doing this all the time, and really well trauma-informed care for clients with complex trauma involves pendulation and continuous present-day integration. These are checkpoints as you build the plan: how am I pendulating, what is the effect of that, and how is this getting integrated and marking differences in present-day functioning?

16. Your questions

1:17:46What if something comes up present day that doesn't connect to the theme we've been mapping, and maybe connects to a different theme?

1:19:15That's a common experience, especially in complex trauma. It's not simple, and it's not just one. It depends on your work with the client. It is very common for me to have one or two themes I'm tracking very actively and intentionally, incorporating and collaborating with the client in tracking them. It often comes down to "there are two core things happening that are creating the highest distress in present day, and those are the things we need to work on first." There may be other themes, but keeping a focus on one or two is important.

1:20:44We may tend to an upcoming situation. Say their dog is their closest connection and gets really sick, and the distress of that comes in and we're managing it in session. I will check: is the theme playing out here? Is Cora able to name how scared she really feels, or is she minimizing, "it's no big deal, went to the vet, everything's checking out okay"? Or can she say "that dog is my whole world, I'm terrified what will happen if anything happens to my pup"? I'm tracking the theme in that. It doesn't mean there isn't other conversation to be had, or a check-in on a secondary theme. But the themes give priority to the conversations and the work. Some things come up that don't connect to a theme, and we address those separately.

1:22:13Are there times when experiences and strategies connect to a different theme, and if so, what do we do with that?

1:22:19Theme identification is not meant to be rigid, "it's got to be exactly right." Your clients are likely to have multiple themes, just as we have multiple clusters of negative cognitions. The task of the therapeutic relationship is to find a way that, together, they tell the story of the client, as a sort of mosaic. The worksheet gives you options to switch out the theme and roll through the steps again. What I find with clients is that the theme does, in some way, come back to a highly representative answer for each component: I am, because, therefore I must. The negative cognitions can switch out, but the suffering and the strategies often become represented by that theme statement. Within the therapeutic relationship, you can create a different theme if it captures another aspect of the client's experience. It's a versatile way to use the tool. Have as many themes as feels necessary, and let the present-day strategies be your access point.

17. Where to go next

1:23:39In our last couple of moments, we want to connect you with some additional resources. Our Somatic Integration and Processing model is where all of this comes from. It's about how we understand a case so that we can formulate treatment plans from a well-intentioned, specific approach, rather than feeling like we have a blindfold on and are grabbing at things, hoping it helps and symptoms decrease, which is often what it can feel like with complex trauma. We can map the case, see the history, understand the past, track the present, and begin to plan for and support the future. We have three days where we teach on it in depth.

1:24:32We also want to connect you with other free resources. There's another free workshop on November 4th, from 12:00 to 1:30 Central: The Case Beneath the Case. We'll continue looking at complex presentations and understanding what's happening beneath the surface. If you're interested in the SIP training, we have one coming up in November, the last one this year, with additional offerings in 2027. All of that is on our course calendar, where we keep the free workshops, the short workshops, and all our offerings.

1:25:20Thank you all so much for joining. We'll keep the conversation going, and we hope to see you in the offerings to come. If you have any follow-up thoughts or questions, email us or connect through the website. Thank you for being here. See you soon.