In theory, the treatment for complex PTSD involves the same exposure-based procedures described for circumscribed PTSD. That is, the evocative stimuli need to be identified and described, the client must be willing to expose him- or herself to these stimuli and not avoid or escape from them, and the stimuli should be presented in vivo. Because complex PTSD involves difficult-to-describe evocative stimuli, however, it is difficult to devise an in vivo exposure treatment that presents the evocative stimuli but then also blocks avoidance behavior. The stimuli involved in complex PTSD are rarely specific things or events. Further complicating the situation is the fact that there are times when the client cannot remember the trauma, or the longer-term, delayed effects are diffuse and do not formally resemble the behavior that occurred during the trauma itself. For example, the behavior during the original classical conditioning might include the experiences of pain, fear, and numbing out. Today, the perpetrator might be long gone or unavailable. It is entirely possible, however, that pain, fear, and numbing out are common occurrences in the client's daily life, even though the eliciting events may be avoided routinely.
The person with complex PTSD may present as an adult who is avoidant of intimacy, does not have a sense of self, and has difficulty trusting others. In this case, even if the evocative stimuli could be specified, such as "becoming comfortable and trusting in a close relationship," it would be unclear how to arrange the in vivo presentation of such stimuli in an exposure-based format. Obvious problems exist with an intervention that consists of the therapist encouraging the client to begin an intimate relationship, to become vulnerable in that relationship, and to stay in that relationship even when anxiety or fear intensify—as would be required for an exposure-based treatment. Even if the client did attempt to comply with such instructions, it is doubtful that the outcome would be therapeutic. The "other" in such an exposure-based treatment might not be patient enough to allow extinction to take place, and worse, might act in punishing ways that would reinforce the original trauma.
Such problems can best be dealt with by using the therapeutic relation ship as a source for in vivo evocative stimuli and thus providing the opportunity to block avoidance. In addition, the treatment of complex PTSD involves the building of interpersonal repertoires that were precluded by the early effects of the trauma, and an establishment of the private control required for emotional responding and development of self (Kohlenberg & Tsai, 1991, 1995).
We believe that FAP can help to produce the conditions that would facilitate the treatment of symptoms of complex PTSD. FAP is a radical behaviorally informed treatment conceptualized by Kohlenberg and Tsai (1991) to account theoretically for the dramatic and pervasive improvements shown by some clients when involved in intense client-therapist relationships, and to delineate the steps therapists can take to facilitate intense and curative relationships. The result is a treatment in which, in contrast to popular misconceptions about radical behaviorism, the client-therapist relationship is at the core of the change process. FAP theory indicates that, in general, the therapeutic process is facilitated by a caring, genuine, sensitive, and emotional client-therapist relationship. It is precisely this type of therapeutic relationship that has the potential for effective treatment of complex PTSD. In the following sections, we describe how FAP provides guidelines for obtaining the type of therapeutic relationship that can (1) lead to identification of the evocative stimuli; (2) provide a venue for presentation of evocative stimuli while blocking avoidance behavior; and (3) provide in vivo opportunities to teach the more adaptive repertoires that failed to develop due to traumatic early life conditions. Following this explication of FAP guidelines, we summarize data that support the utility of using FAP with patients who have complex PTSD.
As described below, FAP is based on (1) three types of client behavior that are clinically relevant, and (2) rules or guidelines for therapeutic technique. Client behaviors include the daily life problems that occur during the session, improvements that occur during the session, and client interpretations of self behavior. Therapist guidelines are rules or methods that are aimed at evoking, noticing, reinforcing, and interpreting client behavior.
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