Complex Trauma Syndrome

By V. Zepinic

Complex Trauma Syndrome covers over a decade of research and clinical experience of complex psychological trauma. This book provides a concept: a practical framework and therapy model in treating complex trauma syndrome. The heart of this book is made up of the practical steps of using the Dynamic Therapy Model of which the author is a founder. This is a patient-oriented, holotropic and phased-therapy model designed to integrate the shattered personality caused by diverse, long-lasting, and pervasive effects of the psychological trauma.
Dr Zepinic defines complex trauma syndrome as involving traumatic events that (1) are repetitive and prolonged; (2) have involved direct harm and/or direct threat to the trauma victim; (3) occur at a vulnerable time in the victim’s life; and (4) have a severe impact upon the victim’s entire life and personality, causing social and cognitive dysfunctions.
This book not only covers unique matters of clinical expertise in research and therapy of the complex trauma syndrome, but also provides a guideline in treating other complex mental health disorders. Multimodal and phase-oriented treatments of complex mental health disorders, as described in this book, are practical guidelines to those professionals who are dealing with mental health issues.

• Language: English
• Publisher: Austin Macauley Publishers
• Release date: Feb 28, 2022
• ISBN: 9781398448780

V. Zepinic

Dr Zepinic is a clinician having over 30 years of experience in treating patients with mental health problems. He is a member of the Royal Society of Medicine (UK), European Society for Traumatic Stress, and the UK Psychological Trauma Society. He is the founder of the Dynamic Therapy model for treating complex PTSD. He was a senior lecturer at the Queen Mary University of London, clinical associate at the University of Sydney and Macquarie University. He is the author of six professional books, has published over 50 articles and served on the editorial board on numerous scientific journals.

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About the Author

V. Zepinic is a clinician, lecturer, and researcher in the mental health; PTSD and other stress-related disorders, anxiety, depression, and personality disorders. He is author of six professional books, two book chapters, and over 60 articles. His biography was published in the Who’s Who in the World book, 2017/18 edition. He is a member of the UK Royal Society of Medicine. He has been editorial board member for numerous professional journals in psychiatry and psychology.

Dedication

To Justus, Joshua, Blake, and Scarlett.

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V. Zepinic 2022

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Acknowledgement

The formative conceptual for this book was born in 1992, when the brutal war in the author’s country of birth (Yugoslavia) and being POW forced him (after escaping from imprisonment) to leave his living place and become part of the biggest refugee crises in Europe since World War II. This book is a little contribution to better identify, clinically and dispassionately, personal wounds of being a refugee. For each of us, there are a series of images, memories, imaginings and other experiences that we received through the media about the war-refugees’ crises, but we are often barely conscious about their struggles and tragedy. For those who have suffered trauma, feelings of warmth and intimacy might have disappeared and any relatedness is tested through the horrible past. Sadly, every year in the world, we see millions of refugees who are often just a number for statistics and research with no attention in regard to their suffering.

Overwhelmed by the negative and painful memories, the traumatised individuals are often not welcome in the environment albeit they are inflicted by a sense of harm and danger. This feeling pervades the individual’s complete post-trauma existence, in a way on which the traumatised persons are commonly unaware. They will always question whether anyone is able to clearly understand the fundamental pathogenic significance of trauma, in particular among those war-refugees who had been the POW. Some severely traumatised individuals will explain that their soul has no time to recover fully and it is taken by the trauma forever.

Consequently, having an odd view of existence, the depressed state and despair are endless and the trauma victims will feel abandoned and valueless. They see themselves incompetent and worthless and largely absent from the conscious sense of the own self. Their traumatic memories are stored in the system which is unable to reach consciousness, self-continuity and self-cohesion (Zepinic, 2012, 2016). Their ego system is dissociated, having a certain amount of the inner conflicts which operate automatically beyond one’s voluntary control and appeared untreatable. For any care-worker or clinician, helping these people is a hard task, but, at the same time, it is a great opportunity to learn about the variety of problems that the war-refugees and other severely traumatised individuals experience.

Anyone who is able to contribute to better understanding of the trauma syndrome should be proud and thankful for such an opportunity. First and foremost, of all that the author of this book accomplished, the most special one is to be a daddy. There are no borders to express my deep and immeasurable gratitude to my daughters (Maya, Nina and Violeta) for all their generous and endless encouragement and full support throughout the years after leaving our country of birth. Although they were victims of civil war in our former country, suffering torture and trauma (and also became refugees), they inspired me to overcome all difficulties and start a new life from a complete beginning.

As a victim of war and being a prisoner of war, I suffered trauma and my recovery and the main healing effects came through my family’s fostering and social support received in a new adopted country. Unlike many other refugees in the world, I have been very fortunate to have such tremendous support which always reminded me that a friend in need is a friend indeed.

This book owes its existence to the numerous individuals—refugees and other severely traumatised individuals who were referred to our clinic for the assessment and treatment due to their enormous trauma that they have experienced. Most of them have been crashed by their unresolved and painful traumatic past and their recovery has been and needed, a long journey. Traumatic memories usually shatter one’s emotional and physical resources and traumatised individuals live in a state of total exhaustion and thus are more prone to the intrusion of a trauma experience.

Painful realities in their past are fulfilled with hopelessness and they are unable to regulate the overwhelming internal and external conflicts. For any clinician or caretaker, helping these individuals is a hard task, but, at the same time, it is a great and rear opportunity to support their post-traumatic growth. In clinical practice, we know that healing one’s trauma syndrome is a matter of time, but it is also a matter of compassion and opportunity to help those in need—whatever we love in clinical practice, there is also a need for our love of humanity.

I am immensely grateful for the given warmth and generosity, for stimulation and pleasure designated by those who understood the traumatised individuals’ needs. As the clinician, I have a great and rare opportunity to provide treatment to the traumatised individuals, such as the refugees and had shared their traumatic memories with them. Their reported painful memories of being forced to leave living place and fears of an unknown new environment evolved my enthusiasm and better understanding of their plight and my certainly further professional development.

I had learnt a lot from my patients and it was my privilege to join them along the path of their tough, arduous, burdensome and formidable journey of the traumatic experience and I am grateful for the exceptionally valuable and impressive lessons I have received from them. I have listened closely to them often struggling even to understand the horror of traumatic event(s). It is quite difficult to find words to describe in full the reported experience of the traumatised individuals, war-refugees, torture victims, as well as those who suffered trauma syndrome as the victims of other human-made traumas, rape, abuse or physical brutality.

I have also had the great privilege of working closely with professional colleagues but above all, my good friends, Dr Kuzmanovski, Dr Ellard (deceased), Dr Marinkovic, Dr Meares, Dr Chuchkovic (deceased), Dr Kluver, Dr Kuroz, Dr Nguyen, Dr Oreb, Dr Tomasevic, who referred to me numerous severely traumatised individuals for assessment and treatment. I have shared the clinical experience with my colleagues and all of us learned a lot from our patients as well.

Finally, I have one wish that, unlikely, will ever be realised: to stop horrible events which make millions of refugees in the world every year and any other human’s inhumanity against humans.

Foreword

It is more important to know what sort of person has a disease than to know what sort of disease a person has.

-Hippocrates (460-370 BC)

Writing about the complex trauma syndrome is writing about this world—the world around us—and the reality that, sadly, has existed throughout the history of human beings. This book is about some aspects of the man-made disasters which we witness every day. In particular, it refers to the refugees’ life; and it is a metaphor for the millions of those people worldwide who are victims of wars, terrorism, political oppression, economic crisis or any other demonic variations forcing them to leave their living place. This book is about some aspects of life in this world and covers over two decades of the research and clinical work with those who are considered as the victims of complex trauma, or being refugees arriving in another country.

The book highlights difficulties of being a victim of the complex trauma; about those who live on a daily basis with fear, shame, guilt and terror of nightmares, flashbacks and unwanted painful memories. The book also provides a practical therapy framework (Dynamic Therapy Model) and a variety of evidence-based approaches for better or proper understanding and conceptualisation of the trauma syndrome symptoms, assessment and help to those who were forced to be different once.

This book, titled Complex Trauma Syndrome, is about those individuals who struggle with their feelings of hate and love at the same time, those who search for safety and trust, about people who are desperate for minimum respect as humans. Most of the refugees and other trauma victims have been confronted with evil, pain, loss, destruction and horror, and they try to rebuild their lives functionally. Even more, refugees are forced to build their lives in an unknown society, new surroundings, face another culture, language, norms and values. It is about human existence in a new society usually indifferent to refugee destitution and marginal life; about those whose personality is shattered and they feel hopeless. The book delivers approaches on how to integrate the shattered personality caused by diverse, sudden or long-lasting and pervasive effects of the trauma experience.

This book speaks about those who are universal but specific, often denied or forgotten in their abyss of existence. It defines the complexities of the complex trauma syndrome as (1) repetitive and prolonged (2) involving direct harm (3) occurring at a vulnerable time in one’s life and (4) having a severe impact on the victim’s entire life and personality. The book provides a view that those who work with trauma survivors should target to achieve their post-traumatic growth in the aspects of restoring their sense of aliveness or vitality, forms of relatedness or interconnectivity and awareness of inner and outer events.

The book is welcome to those who work with traumatised individuals in any society all over the world, assisting victims of war, terrorism, political violence, torture, rape or domestic violence and abuse. It is about universal knowledge and experience in coping with the powerlessness, emotional deadness, uncertainty and daily desperation for a better life. Work with severely traumatised individuals requires full compassion and passion which could cause a compassion fatigue in professionals who deal with such complex issues.

Refugee problems and their needs are public issues worldwide as every year, the world is faced with millions of new refugees. However, the knowledge and understanding of their needs surprisingly is not widespread often due to a silence surrounding these human tragedies. It is evident worldwide that indifference about traumatisation is intentionally put under the carpet or marginalise the needs of those who want freedom from tyranny, abuse and oppression.

We are well informed that refugees exist but even when they become part of our society and reality, we try to deny impact on their lives and, in general, awareness of refugee problems and their needs is very low. Ignorance and denial prevail even among those professionals who work with traumatised individuals and in many countries, different political and social strategies are aimed to discourage trauma victims (e.g., rape, domestic violence or abuse) from speaking out and seeking protection and security.

Despite significant development in helping trauma victims, they are still not widely and systematically known to the health and social providers and professionals in this field (e.g., general practitioners, lawyers, social workers, healthcare professionals). In many instances, those who are dealing with, for example, severely traumatised refugees, are with limited power and not able to provide sophisticated help strategies. In many countries in the world, some strategies are not designed to provide needed help on a permanent basis and, as a consequence, the refugees who are already traumatised increase their stress condition and feel helpless and hopeless. Most problems related to a lack of help are related not to the care workers but to others; namely, politicians, legislators and leaders of the free world.

This book is a comprehensive theoretical and practical guideline for the treatment of the trauma syndrome patients; in particular, those who have been traumatised due to war, torture, violence or political oppression, or anyone’s inhumanity to humans. It has become increasingly important to apply a perspective to review existing knowledge and practice in the field of defining and treating trauma victims and provide better directions how to help those in need, as well as for future research in this area.

In essence, it should be clear that psychological trauma caused by man-made disasters (forms of interpersonal violence) is a perennial problem—wars, terrorism, crimes against humanity, sexual abuse, torture—all make trauma a horrible leitmotiv of our everyday life. Psychological trauma is typically chronic or long-lasting rather than a one-time condition, limited with a clinical picture showing deterioration in mental health and physical disabilities, weaknesses on the standardised measures of everyday living, and remarkable homogeneity in expression of psychiatric disorders.

Studies on traumatised individuals revealed that a chronic state of the traumatic experience is a transient mental illness which lasts endlessly. In a study among twenty war prisoners from former Yugoslavia who obtained refugee status in Australia (Zepinic, 2001), it was revealed that 100% of them reported symptoms of chronic PTSD with a high risk of suicidality as a result of lost identity, social withdrawal, estrangement from others and a depleted or lost sense of self.

In another study (Priebe, et al. 2009), it was revealed that among the 4,167 refugees from the Balkans, 63% of those who found refuge in the western European countries reported PTSD and major depression ten years after the war. In his study, Zepinic (2011) revealed that the traumatised refugees suffered: (1) alterations of ability to modulate emotions, (2) alterations in identity and sense of the self, (3) alterations in the consciousness and memory, (4) alterations in relations with others, (5) alterations in physical and medical state and (6) alterations in the system of meanings.

The Complex Trauma Syndrome book focuses on a complex psychological, social and emotional sequalae that trauma victims experience being exposed to multiple traumatic events followed by forced power and/or victimisation on a daily basis. It describes how the trauma event(s) impacts the psychic core of the soul of trauma victims and generates a search for meaning as to why the traumatic event(s) leads to a decentring of the self, loss of groundedness and a sense of sameness, continuity and ego fragility—leaving scars on one’s inner agency of the psyche. The traumatic experience is often complex, multiple and long-standing, which causes important implications on both the patients and clinicians. Within this heightened awareness of the everyday problems—essentially all that are unpleasant—any ignorance of these problems reduces the approaches for help and management.

The traumatic condition is quite a controversial topic, and is complex enough itself regardless of all efforts provided to help. The traumatic experience often overwhelms the capacity of one’s well-being and knocks out ordinary functioning, throwing trauma victims into confusion and extreme disarray. The traumatised self seems to be vacuumed and emptied of its vitality and aliveness, which demonstrates that the self-structure has lost its sense of cohesion and continuity, and suffered a disruption, rupture and disunity of the self as a whole. In most extreme cases, the self remains turned apart and incomplete, with its loss of unity and wholeness.

Without any doubt, war refugees are a very vulnerable group with a history of multiple traumas. They are people who have been forced to leave their living place or country and seek refuge or asylum status elsewhere. Most of them, if not tortured, have severely been traumatised to the extent that they had no other choice but to escape leaving behind what they had developed over decades. At an individual level, the impact of any forceful and unwilling leaving the home place causes feelings of uncertain future, the sense of non-existing, powerlessness and hopelessness.

The refugee status, for example, is itself a shameful and embarrassing experience. In this book, it is defined alongside with the original trauma by separation and forceful migration, the trauma-after-trauma experience of refugees which the author of this book defines by the five D’s: dehumanisation, dislocation, disintegration, dispossession and disempowerment.

In essence, this Complex Trauma Syndrome book is composed within its eleven interrelated chapters. Chapter 1 describes what constitutes the refugee trauma describing a refugee’s feeling like a fish out of water, having profoundly isolated position. It is evident that in the refugees, their emotional distress overwhelms the ordinary capacity to bear feelings. The most profound distractions in the war-related refugees are that they feel hopeless, helpless, with intense fears and anxiety and a loss of control.

Following exposure to the extreme stressor(s), the war-related traumatic memories are framed by sequences of the exposure to the threat of death or body integrity, or to the loss of loved one, or being exposed to the danger, or by witnessing horrifying images of threat and trauma. As a consequence, such refugees are unable to regulate memories or their emotional content even long after they escape from the trauma environment but still persistently experience the images, thoughts or perceptions of the traumatic event(s) in the form of nightmares or flashbacks.

Refugees are usually individuals who have experienced an accumulated trauma, horror, prosecution, intimidation or torture experience. They have suffered an unimaginable loss of family, friends, home, community, country, occupation, culture, customs and the opportunity to communicate in their mother language. They generally found themselves subjected to the poverty and discrimination as well as the loss of sense of self, legal status, and self-identity. As a consequence, they are unable to make the best of the situation in which they find themselves using whatever help is available to rebuild their lives (Fox, 2005).

Chapter 2 describes the trauma-after-trauma phenomenon, a unique condition with refugees who are overwhelmed by anxiety and fear of the unknown environment (new living place), fear and uncertainty about the future, homesickness and uncertainty with what happened with loved ones left behind. New environment could be a shocking experience for the refugees in regard to their culture, customs, language and often the inability to find any real chance for the employment. It is common that the honeymoon of a settlement in their host country became questioned by the refugees about prosperity to rebuild a new life.

The trauma-after-trauma phenomenon may slow a process of accepting offered help and assimilation into a new environment and to recover from a universal set of reactions of the original refugee trauma. Similarly, this phenomenon may cause an alteration of a normative response to received help and the therapy in a new society (Zepinic, et. al., 2012). In such situation, the individual’s response leads to a cascade of the events that result in the increase of symptoms of the hyperarousal, dissociation, detachment, depersonalisation, recollection of the intrusive event(s) and the avoidance of reminders. The services which provide a help to the refugees should identify those who are at an increased risk for the symptoms as an aftermath of the settlement; they should be treated early and their settlement should be managed to possible prevent further deterioration of trauma condition in due to trauma experience.

Zepinic, et. al., (2012) found a higher level of PTSD and associated disorders (anxiety and major depression) among the highly skilled refugees from the Balkans, a decade after settlement in the UK rather than immediately after their arrival from the country of their birth. Reportedly, the refugees were also prescribed more with antidepressants a decade after arrival to the UK than when they escaped from their war-affected living places. Both trauma and the post-trauma risks were found important, however the post-trauma factors as an additional life stress were more a contributing factor not only in the failure of the treatment provided or treatment-resistant condition but also in causing further deterioration of the refugees’ mental health condition.

The extent of post-trauma factors may limit the effect of provided therapy and/or help and refugee recovery from the psychological disorders. Weine, et. al., (1998) found among the refugees from Bosnia who are settled in the US that three major symptoms occurred most frequently with the highest severity ratings: avoiding thoughts of the war, intrusive memories and being upset when reminded of the trauma. At a follow-up study with the same refugees, there were different reported symptoms: being upset when reminded of the trauma, intrusive memories and feelings that the future is unclear.

The refugees who escape the war-affected places face with two additional stressors—the separation and adaptation trauma. It is important for those who are involve in providing help to the refugees to acknowledge that the refuge is in fact a forceful, unwilling, unwanted and undesired process. It is a condition which occurs usually after a very painful and traumatic experience followed by an enormous uncertainty in regard to the new environment and the future life.

Chapter 3 mentions the most used psychometric instruments to assess complex trauma syndrome using standard inventories and tests. There are numerous instruments to assess symptoms of PTSD; however, the most important is that this severe disturbing condition of any trauma victim should be assessed in sophisticated ways. The author of this book is of the opinion that a complex trauma syndrome (complex PTSD) due to the prolonged or repeated trauma is an iceberg for the clinicians. Severe trauma often causes fragmentation of the body-mind-self structure with the traumatic memories which causing discomfort, avoidance, difficulties in daily functioning and shame.

While describing the most used methods of assessing PTSD, this book also describes other stages needed to complete a full picture of one’s suffering: (1) standard clinical assessment, (2) assessment of trauma-related symptoms and disorder, (3) assessment of social functioning and (4) assessment of personality structure. This means that assessment of the impact by the trauma is a constant process which is not ended using results of the psychometric testing, or the clinical interview. With severely traumatised individuals there are multiple problems not only related to the mental but physical health too, as well as social adaptation during post-trauma period.

Other stress-related disorders (reactivity attachment, adjustment disorder and dissociative disorders) are an aftermath of quite distressing and disabling response to a stressful life event or series of events. They may manifest as emotional and/or behavioural symptoms with characteristic clinical features although some clinicians are of the opinion that they are sub-syndromic conditions. By convention, if following exposure to a stressful event(s), a subject’s psychological or behavioural reactions cause impact on patient’s personality and functioning, these disorders cannot be abandoned even if not fully satisfied diagnostic criteria to be seen as an independent disorder.

Those who work with trauma victims often face a situation that all the problems and personality changes related to traumatic experience are hidden by the patients who try to keep that inside, fighting their own inner conflicts. This problem is described in Chapter 4, which focusses on the fact that severely traumatised individuals have a condition of self-fragmentation or depletion, emotional detachment, emotional inhibition or emptiness and a sense of being outside of the own self. This condition is a constant struggle for the trauma syndrome patients in an attempt to resolve the inner and outer conflicts.

The severely traumatised individuals not only experiencing overwhelming sense of terror and hopelessness but betrayal by the own self (e.g., My self is not mine or My self is a stranger to me), which may lead to somatosensory disturbances (visual, tactile, or olfactory sensory); disturbances which are well repressed, unconsciously organised and stored in memory in a form of the pathological conceptualisation. Foa, et. al. (1998) stated that the most evident stress reactions among the severely traumatised individuals are an intense fear of trauma repetition or trauma-related stimuli and general diffuse anxiety.

With severely traumatised individuals, we can find two features of the trauma syndrome: (1) compounded reactions which include depression, psychosis, psychosomatic disorders, suicidal thoughts and (2) delayed response which includes changes in one’s personality and inability to control over everyday life. As the trauma victims are usually overwhelmed by these symptoms and plunged into a hypnoid state (personality split off), they are unable to recognise and restore depleted sense of self into a meaningful mental content.

Because of that, severely traumatised individuals are likely to experience overwhelming feelings of helplessness and utter terror due to unconscious traumatic meaning shatters the perception of the self and the trauma victim-the outer world relationship cannot be restored easily and adequately. Severely traumatised individuals are usually run by unconscious memories of the event(s) that are deeply inside, which the trauma victim is consciously unaware of.

Memory of traumatic experience is itself a puzzle for clinicians, patients, family members and researchers. This issue is so important that many clinicians pointed out as a key factor in understanding complexity of the trauma syndrome. Consequently, many of the essential elements of assessment and therapy involve working with the memories. Understanding the effects of the trauma on one’s memory is critical to the therapeutic approach on trauma syndrome—the issues of a great practical and theoretical importance. In this chapter we focus on two broad areas: the effects of traumatic experience on memory and findings of memory forgetfulness, in particular about memory of childhood trauma event(s).

Chapter 5 describes a process of the connectedness between the trauma victims and the outer world. As stated previously, their process of the adaptation and assimilation could sometime be equally stressful as it was by the original trauma. In general terms, adaptation into a social environment could reach three main goals: personal, interpersonal and social or cultural.

In many instances, the effect of provided help is complicated by the cultural differences. Cultural, socio-political and socioeconomic factors play quite significant role in anyone’s psychosocial rehabilitation and adaptation. The relationship between chronicity of the trauma and migration is common and influence the effectiveness of provided help and treatment in host country.

Certainly, one of the most prevalent problems in adaptation to the new environment is a language. To learn a new language is not an easy process, in particular for adults with a severe stress-related condition. Traumatised individuals usually complain of their evident problems in concentration what is an additional factor that learning new language is not easy task what makes refugees even more unhappy and/or disappointed. Traumatic memories may prevent refugees from learning new language faster and more effectively simple because they have been deprived abruptly of what was most meaningful in their entire lives.

Language plays a significant part in expressing their perceptions and personal feelings of the refugees’ psychopathological condition. These difficulties are associated with the cultural differences and/or education recognition of skills achieved in the country of birth. Because of the feelings of guilt and worthlessness, the refugees may fail to effectively utilise healthcare and other provided services in order to help them to faster adaptation and assimilation into a new environment.

Chapter 6 of the book describes steps which trauma syndrome victims should undertake to find their way through to feel human again after their traumatic experience. Through the trauma exposition, many individuals’ capability and previously functional coping mechanisms become ineffective and vulnerable. In reality, the post-traumatic growth is a very long and difficult process which requires full cooperation between those who are in need and those who provide them help and care. Because of specific circumstances which forced them to leave their living place, the refugees are often inadequately resourced to face and endure the realities of their situation. Instead, their resources are depleted and employed in trying to avoid recognition of their vulnerability and lack of continuity.

Some of the traumatised individuals may demonstrate remarkable resilience and, despite being treated by the protective authorities in regard to their safety and security, they remain more connected with their inner forces (conflicts) that make them chronically helpless and hopeless. They are unable to tolerate and endure their inner conflicts and losses without becoming overwhelmed by that. As a consequence, they are unable to make the best of the situation that they arrived in a safe host country which services are willing and dedicated to provide help and care.

Certainly, to build a new life is a long and challenging process which requires a lot of personal challenges which the trauma syndrome patients often cannot admit. Indeed, this may produce their primitive defensive manoeuvres (splitting, projection, disavowal) which leave them locked into the world of pain and resistance to any challenges. In this way, the refugees in particular feel intolerable and not prepared for new adaptation whatever is available and offered to them.

Those who work with trauma victims are often faced with individuals who have lower or depleted self-esteem, unable to find employment and who live on minimal benefit and who see their future as uncertain. For refugees, survival is the first step upon arrival in host country is a short-living goal and they then start to make a plan for the future with many obstacles. Many will express disappointment in the absence of support to reach their plans not having kindly welcome holding an idealised view of the generosity that wait in the host country (Zepinic, et. al., 2012) and they could develop a sense of being let down by a host country.

Through the period of adaptation, some refugees quite difficult admit that they face with the unachievable goals and that their plans are often unrealistic. Their inner resources are also inadequate to re-establish the self-cohesion and continuity needed to fulfil some goals what could be another factor to increase or further development of disordered mental health.

Two key areas of the help to trauma victims are social and psychological support described in detail in Chapter 6 of the book. The framework of social support is a series of interrelated settings that are embedded in each other and influence the individuals directly or indirectly through the multiple relations within the community, family members and the peers. Many researches have confirmed that the social support may significantly contribute for recovery of the stress caused by trauma and separation from the own self.

Open and free talk about the stressor(s) and positive emotional climate are the key elements predicting a long-term adjustment and decrease the severity of the stress-related symptoms. With positive attitudes and support, the trauma victims develop better coping skills and ability to redevelop a new relationship with friends, or even with own family and significant others. This also delivers challenges in the patient’s mind and psychological response to the traumatic events(s) which occurred in the past.

Beyond social support, the sense of belonging to the community, social cohesion and social capital have significant positive impact on the mental health outcomes, whereas a lack of the connectedness, identity and supports inherent in a sense of community may result in less positive outcomes (De Silva, et. al., 2005; Eastmond, 1998; Falicov, 2005; Zepinic, et. al., 2012). Without any doubt, the absence of an adequate social support may significantly impact the effectiveness of the provided psychological help which targets the challenges in the trauma victim’s perception of self, relationship with others and a general philosophy of life.

These goals should lead to personal strength, new possibilities, relating to others, appreciation of life and spiritual challenges. With the traumatised individuals, there are changes in self-perception reflecting significant disruption in the assumptive world; the experience that the world is a dangerous place, unpredictable, a world in which one’s own vulnerability becomes clear and silent.

Psychological help to stress syndrome patients should be multidimensional, grasping the awareness of their personality downhill, emotional, cognitive and attachment distortions. It is usually a long-term intervention in order to achieve one’s personal, emotional and cognitive regulation, inter and intrapersonal effectiveness, tolerance to distress imposed by the inner conflict drives and the traumatic memories, the coping strategies, the self-cohesion and self-management.

Without any doubt, Chapter 7 is the heart and the brain of the book, focussing on Dynamic Therapy Model in treating trauma syndrome. The founder of this therapy model is the writer of this book. While providing some psychological help to the severely traumatised individuals, the concept should include: (1) the nature of the predisposing factors in trauma condition; (2) the manner in which the trauma experience and conditioning produce distortions of the trauma victim’s personality; (3) the relationship between the personality structure and trauma; (4) the constituents on the inner conflict drives and their aftermath; (5) meaning, function and manifestations of the trauma syndrome; (6) the structure of their psychic apparatus; and (7) the mechanism of defences.

We also conceptualise that practical framework for providing psychological help should be focused on the disturbed emotions, shattered sense of the self, broken relatedness and unconscious traumatic memories which blocks the traumatised individual’s functions in the sphere of self (Zepinic, 2011). In severe trauma, the victims may express a sense of identity diffusion, fragility and strong feeling of discontinuity with severe disruption in regard to the intra-psychic and interpersonal relationships.

The Dynamic Therapy Model is phased patient-oriented treatment which applies to the holotropic integration of the distorted self into a whole. The main concept of the model includes three treatment goals: (a) restoration of the relatedness (Interconnectivity); (b) restoration of a sense of the aliveness/vitality (Dynamism); and (c) restoration of an awareness of self and inner events (Insight). The model is flexible and adaptive in treating other complex disorder not only trauma syndrome and stress-related disorders. Dynamic Therapy Model has been developed as a result of the research and therapy experience in working with over 800 severely traumatised individuals for over two decades.

The founder of the model is of the opinion that the Dynamic Therapy Model is rather a process than a special therapy—it is in use as the basis for intervention and it is explicitly given as a rationale for the treatment of complex trauma syndrome and other complex disorders, with three main domains: (a) changes in the perception of self; (b) changes in the experience of relationship with others; and (c) changes in one’s general sense of the purposes.

Needless to say, the war-related refugees represent the most seriously affected population by the severe traumatic events. Escaping from the dangerous place where they experienced traumatic even(s), the refugees have only in mind how to find a safe place regardless of an eventual long and dangerous journey. In the early stage of their refuge, they are trying to put behind their past with a plan to be autonomous and independent individuals.

However, after an initial settlement in the host country, some of the refugees can show severe homesickness syndrome, which is described in Chapter 8, as their demands and expectations cannot be always fulfilled. In a new environment, the refugees should learn to be a person again, to redevelop the self-image and identity, to deal with the ambivalence, doubts and uncertainty. They should understand the context and vicissitudes of the life, to reshape relationships and friendships and to form new relationships. All of these they had before, but lost in their country of origin and fulfilling these demands is quite important not only to see new country as a welcome place but to avoid feelings of the homesickness.

Homesickness is an outcome of the refugees’ reality that the honeymoon of arrival in a new environment is not a long-lasting and forever as they soon face tasks to adaptation under specific circumstances. They should find for them meaningful goals, orientation and definition of a new cultural system. Living in a host country under unknown social and political structures, often with difficulties in communication due to the language, makes refugees difficult to identify with cultural and moral values, even more when moral judgements are questioned by brought values from the country of origin. After arriving in the host country, the language problems and cultural differences may impede expression and regulation of emotions and can lead to more acting out behaviour, loss in self-confidence and lower self-esteem.

There is no doubt that culture, gender and age play quite a significant role in dealing with the trauma victims and these are the topics of Chapter 9 in this book. Many female refugees come from societies where women’s role is primarily focused on the home and family and they need particular attention and support while trying to cope and integrate in a new cultural environment. They cope with the trauma and migration in different ways and need different approaches to alleviate their suffering. There are evidences of a high prevalence of PTSD in female refugees and approximately, the prevalence is twice as higher as for men. Females also show more reluctance for releasing real symptoms of the trauma, not only because of the stigma, but due to the anxiety that it will affect their children’s status.

As an aftermath of the refugee status, males are more likely have a history of alcohol or illicit drugs abuse; women usually suffer from depression and anxiety. Using the measurement of the GAF score, many researches revealed that the female refugees are more at risk of developing anxiety or depression and similar results are found among asylum seekers (Silova, et. al., 1997).

It is also important to note that suicidal behaviour is found to be much higher among female refugees than in men, in particular among those women who had been exposed to sexual assaults or rapes (Avina, et. al., 2002; Drozdek, 2014; Foa, et. al., 1998; Herman, 1992; Zepinic, 2018). Women also complain more about symptoms related to the part of the body exposed to a trauma experience. They often report sexual dysfunction, pain on different parts of the body, sudden numbness and muscle spasms. Rape victims, in particular, report symptoms of a chronic pelvic pain, headaches and gastrointestinal disorders and menstrual irregularities.

Professionals who deal with the traumatised female refugees should establish cultural and an empathic atonement in attempt to develop: (1) common ground in understanding and defining the problems and (2) negotiate for an agreement concerning goals for recovery. The care should be facilitated process in which full subject’s involvement will deliver not only effectiveness of the provided help but will improve the refugees’ sense of personal values and will empower female refugees to avoid some negative stereotypes about women from the country of origin in a host country.

Working with traumatised children is always a sensitive and delicate task with additional difficulties if they are orphans due to the war. There are complexities of language and communication using an interpreter as they are not willing to talk in front of an unknown person. The issues about cultural differences between refugee children and care-workers can also cause great confusion, lack of the child’s participation and the child’s uncertainty about the purpose of the interview. Any interview with refugee children should be with time and a flexible approach before, during and after the interview to establish a working relationship.

When a refugee child has been abused or in other ways traumatised, the interpreter as well as care-worker should overtake some familiarity with premorbid condition that is a subject of the professional help. An emotional impact on children who witnessed the traumatic event(s) and experienced violence left them with a panic attack, flashbacks, re-experiencing and dissociation. Those who are orphans sustain further traumatisation arriving in the host country alone, afraid, fearful, insecure, terrified, scared and vulnerable.

The turmoil of traumatised children is enormous and very powerful; they have a broken attachment, adults around them from their country of the origin who are concern about own uncertainty and preoccupied with the own family. Orphans do not have secure base within their vulnerable and fragile, or broken, personality with minimum grounds for emotional and post-traumatic growth.

Chapter 10 of the book illustrates processes of empathy, trauma transmission and countertransference. It is common while working with severely traumatised individuals that the clinicians and care-workers should provide a capacity of empathy and effectiveness. However, everyday work with severe traumatised individuals is also a form of the traumatic encounter in itself which can be defined as a vicarious traumatisation (Herman, 1992; Zepinic, 2011), compassion fatigue (Figley, 1997) or empathic strain (Wilson, et. al., 1994).

Empathic attunement can be defined as one’s capacity to resonate efficiently and accurately to the trauma survivors or to the refugee’s feelings of being refugee and the attunement requires a proper knowledge of the internal psychological state elements, unconscious and conscious, in particular the refugees’ inner conflicts and traumatic memories. In essence, the empathic attunement is a cornerstone while dealing with the traumatised individuals. It is a capacity and an art to be a good listener for trauma victims who reveal stories about their traumatic experiences and aftermaths. It is common that those who work with traumatised refugees should also deal with trauma-specific transference (Zepinic, 2012).

An empathic atonement is a part of one’s decoding process, selection and detection of the information flowing from the trauma syndrome patients to the clinician who, in some basic respect and understanding, transmits and selects importance of the reported feelings as a message which should be decoded. This is also an instructive process for any further intervention and decision making of type and modes for the help being provided. Despite all professionalism, it is highly possible for those who work with the severely traumatised individuals to face the trauma-specific transference reactions. Empathy is the process and capacity to identify and understand other’s psychological state of being (Wilson, et. al., 1994) and it is defined fundamentally as a form of knowing information processing and data collection about the person’s conscious and unconscious state.

Trauma-specific transference is an unconscious projection of the entire person somatically and psychologically that could be seen in a form of unconscious projection of the trauma victim’s traumatic experience upon the care-worker or the clinician. The trauma-related transference reflects the trauma victim’s feeling of hopelessness that harks back to the time of the trauma exposure. Although the trauma is over, the traumatic memories of such powerless and often hopeless condition may extend into all subsequent relationships, even with the clinician. The trauma experience reported is a contagious and the clinician’s role as the witness while providing help may emotionally overwhelm the professionalism. An inexperienced clinician may experience to a lesser degree the same terror, rage, loss of trust and despair that the traumatised patients report.

As traumatic experience may shatter all structures of one’s self, its coherence and continuity, the main task in working with trauma syndrome patients is the post-traumatic growth, detailed in Chapter 11 of the book. The possibility for growth from the struggle with suffering and crisis is a great opportunity to escape from darkness of despair and move forward which makes the trauma victim’s feeling of being part of the main again. A better sense of the closeness and freedom to be oneself, disclosing socially undesirable traumatic experience, the trauma syndrome patients recognised themselves as the individuals able to deal with their traumatic past and losses.

The post-traumatic growth is a complex process focused on: (a) transformation of the self, (b) challenges towards new relatedness, (c) adaptive functioning, (d) relapse prevention and (e) self-containment. It is designed to make traumatised individuals able to walk on the road without guideline and proper professional help (Zepinic, 2011) with an achieved greater self-awareness, new knowledge of perceived experience and more adaptive behaviour with a greater capacity and cohesive sense of self. Post-traumatic growth is an independent and mature completion of a long journey to recover from the broken spirit; it is a new growth and a starting point for new life. It is a demand for the inner changes with a new configuration of identity and self-dimensions with their functions in qualitative different manner.

The book Complex Trauma Syndrome presents a better understanding of the severity and complexity of one’s personal trauma and fears. It also captures the enormous knowledge and clinical experience of working with trauma syndrome patients who are, just as we are, humans who suffered such a horrible experience being victims of trauma, or like refugees being forced to leave their living loved place. The knowledge about them and their needs are widespread although they can be sometime left uncounted. This book is a recognition of broad information about traumatised individuals, their vulnerability and various post-traumatic syndromes that includes those of the trauma-after-trauma phenomenon (in this book identified as complex traumatic stress reactions).

This is of critical importance because this is what has not been recognised in the traditional conceptualisation of PTSD. This book tends to acknowledge that the complex trauma syndrome is not an ordinary traumatisation within the concept of the diagnostic evaluation of traumatic stress (PTSD). The severe (complex) trauma is often repetitive, may be chronic, involves betrayal and may alter the entire personality and derail the trauma victim in a variety of life spheres. It is critical that professionals who work with trauma syndrome patients begin to understand much of the material that is included in this book so that they can increase knowledge and awareness and also expand their range of intervention.

Introduction

Despite human’s capacities to adapt and survive, severe traumatic experience may alter people’s psychological, biological and social equilibrium to such a degree that disintegration of the personality could be so severe that the own self is seen as a stranger to the body. The trauma experience interferes in paying attention to here-and-now circumstances in both new and familiar situations and attachments. Severely traumatised individuals may concentrate selectively on a trauma reminder, their life might become colourless, learned and contemporary experiences cease to be guidelines in post-trauma time. This could be in particular seen with war-affected individuals whose life and everything built in the past is suddenly gone.

Due to wars and social unrest in many countries, the number of refugees in the world increased dramatically in the last 20 years, as for many reasons they have been forced to leave their homes—from politically and economically unstable countries as well as from war-affected countries—become refugees seeking hope and asking for help in other countries. Many of them are victims of war and torture, political oppression in all their insidious forms of human degradation and their lives are often dominated by fear, shame, guilt and post-traumatic stress disorder, as well as other stress-related illnesses. Their life-threatening experiences, traumatic memories and nightmares are often non-understood conditions, even by loved ones or professionals.

According to UNHCR’s Statistics Database, in 2019, 79.5 million people were forcibly displaced worldwide (the highest levels of displacement on record) and 25.9 million have been considered as refugees, over half of whom are under the age of 18. Further, there were also 4.2 million stateless (asylum seekers) people who have been denied a nationality and access to basic right such as education, healthcare, employment and freedom of movement. In a world where nearly 151 people are forcibly displaced every minute (217,808 people a day), it is an unresolved question on how to deal with those people in need. Because of conflicts and persecutions, 38,000 people a day are forced to flee their homes and many people imply a high risk of sustaining potentially traumatic events.

Forced displacement and often hazardous escape from the conflict zone are associated with additional threats, fears and uncertainty. Dose-response relationship between trauma exposure and severe psychological impairment is well documented (Ager, 1999; Beiser, et. al., 1995; Papadopoulos, 2005; Silova, 2002; Steel, et. al., 1999; Summerfield, 2001; Wilson & Drozdek, 2004; Zepinic, 1997, 2011; Zepinic, et. al., 2012). Accordingly, refugees have generally been shown to present a high prevalence of mental health problems, particularly post-traumatic stress disorder, depression, personality disorders and anxiety compared with the general population as well as to the non-refugee migrants (Adjukovic & Adjukovic, 1998; Steel, et. al., 2009; Zepinic, et. al., 2012).

Studies suggest that the adverse effect of the traumatisation is often evident a long after escape from the living place (Zepinic, et. al., 2012). Researches also suggest that length of settlement procedure in the host country, insecure visa status, prohibition to work account or education, are a substantial proportion of the psychological distress. Essentially, introduction of the PTSD diagnosis in diagnostic manuals (DSM and ICD) has opened door for studies and a clinical approach to investigate the nature of human suffering. This, in particular, stimulates scientific investigation about human’s inhumanity to humans which more significantly causes impact upon the trauma victim’s psychological equilibrium disorder largely dependent on the severity and complexity of the suffering.

Exposure to extreme stress (e.g., combat, brutal rape, terrorism, domestic violence) is widespread and numerous studies revealed that one out of four individuals are victims of some type of trauma in their lifetime. For example, a survey of 1,245 American adolescents (Kilpatrick, et. al., 2003) showed that 23% had been the victims of some physical or sexual assaults, as well as witnesses of violence against others and one out of five of the exposed developed PTSD.

Another study (Elliot & Briere, 1995) found that 76% of American adults reported of having been exposed to extreme stress in their lifetime. Zepinic, et al., (2012) in a study of the 854 war-refugees from the Balkans found that 52% of the interviewed reported symptoms of PTSD and depression twenty years after escaping from their war-torn country. This study also revealed that 53% of the interviewed reported still taking some psychotropic medication due to their stress-related conditions.

Numerous studies revealed that, among the refugees, lack of integration into a new society causes absence of all positive thinking, feelings of not wanting anything and they do not try to get something that was wanted. The studies also revealed that the war-trauma victims believe they would not get better, nor solve personal problems, would have nothing to look forward to, would fail to achieve personal goals and viewed their future with a pessimism. These issues about integration should be investigated in any refugee population in order to obtain a real picture of refugees’ mental health upon their arrival to a host country and how to receive support and resettlement (post-migration factors) impact their mental health.

However, most people who had been exposed to traumatic event(s) are somehow able to go with life without becoming haunted by the traumatic memories of what happened in the past. That does not mean that the traumatic memories go unnoticed as they could be deeply unconscious—a volcano that may erupt anytime triggered by a reminder. After exposure to trauma, most people become unconsciously unaware of trauma impact on their personality.

Some could be preoccupied with traumatic event(s) having involuntary intrusive memories which is a normal way of responding to the dreadful experience (Herman, 1992; Horowitz, 2001; van der Kolk, et. al., 1996; Zepinic, 2011). Repeated replaying of traumatic memories serves one’s function of modifying the emotions associated with the trauma. However, some of the trauma victims are unable to integrate the awful experience and start developing specific abilities of avoidance and hyperarousal associated to the traumatic event(s) despite the passage of time.

Trauma exposure is of significant professional concern as it impacts the trauma victim’s personality in quite complex ways (Zepinic, 1997). They are the victims of extreme stress and might be seriously affected by the overwhelming challenge of trauma and thus may enter recovery with limited cognitive, affective and behavioural burdens resulting in a spectrum of post-traumatic outcomes. It is commonly evident that traumatised individuals display a wide range of post-traumatic reactions, including PTSD, the controversial disorders that may follow a traumatising experience. PTSD was formally included in the list of psychiatric disorders in 1980 with publication of DSM-III (APA, 1980) and the identification of a triadic cluster of symptoms (re-experiencing, avoidance and hyperarousal) documented in the Vietnam veterans and in rape victims and later applied to adult civilians.

The revised fourth edition of the DSM (APA, 2000) refined consistently the diagnostic criteria for PTSD clarifying Criterion A as follows:

The person has been exposed to a traumatic event in which both of the following have been present:

The person has experienced, witnessed or been confronted with an event or events that involve actual or threatened death or serious injury, or a threat to the physical integrity of oneself or others.

The person’s response involved intense fear, helplessness or horror. Note: in children, it may be exposed by disorganising or agitated behaviour.

Since DSM-III was published, many clinicians (Blank, 1994; Briere & Spinazzola, 2009; Courtois & Ford, 2009; Foa & Rothbaum, 1998; Herman, 1992; Horowitz, 2001; van der Kolk & Courtois, 2005; Zepinic, 2011, 2018) were of the opinion that diagnostic criteria for PTSD does not include all aspects of the trauma impacts. The researchers and clinicians have been of the opinions that PTSD symptomatology may be expressed very differently according to the type of traumatic experience, its severity, duration and the context of the trauma. In its fifth edition (APA, 2013), the DSM-5 redefined Criterion A as follows:

Exposure to actual or threatened death, serious injury or sexual violence in one (or more) of the following ways:

Directly experiencing the traumatic event(s).

Witnessing, in person, the event(s) as it occurred to others.

Learning that the traumatic event(s) occurred to a close family member or friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.

Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse).

Note: Criteria A4 does not apply to exposure through electronic media, television, movies or pictures, unless this exposure is work related.

This redefinition emphasises the threatening nature of the trauma upon the victim even if not directly experiencing or witnessing the traumatic event(s). The myriad of studies on the traumatic stress and revision of the diagnostic criteria demonstrate that researchers and clinicians have recognised the importance of identifying trauma impacts upon the victims and development of stress reactions, especially for a chronic and complex traumatisation, which is often found among the war-refugees.

Chronically (severely) traumatised individuals often display a conglomeration of the trauma-related symptoms that imply extensive problems and alterations of the self-continuity and regulations together with problems in the attachment relationships, dissociation and inability for self-control—in essence, it represents a complex trauma syndrome (complex PTSD) rather than a simple disorder.

Numerous clinicians (Allen, Briere, Cloitre, Courtois, De Jong, Foa, Ford, Herman, Horowitz, Resick, Spinazzola, van der Kolk, Zepinic, …) are of the opinions that definition of the complex PTSD is needed to clarify the extreme trauma experience. The new version of the ICD-11 (WHO, 2018) introduced a new diagnostic category—complex post-traumatic stress disorder (CPTSD)—as a sibling disorder to PTSD.

The CPTSD describes a symptom profile that is a result of an exposure to multiple or repeated adverse events, including child abuse, torture and severe domestic violence. The ICD-11 describes that CPTSD patients suffer symptoms of reexperiencing, avoidance and a sense of threat as well as three additional clusters symptoms—affect dysregulation, negative self-concept and difficulties in relationships—which are described collectively as disturbances of self-organisation.

Based on a clinical experience, there is evident need for further investigation into the necessary multimodal assessment and the use of various psychometric instruments to better screen a variety of the issues among the traumatised individuals. Thus, any complex trauma interventions should address safety, self-regulation and an integration of the traumatic experience needs to be considered and further investigated in order to achieve the post-traumatic growth (Courtois & Ford, 2009; Herman, 1992; Zepinic, 2011). On the contrary, due to proper steps not taken in post-traumatic growth, the severely traumatised individuals could develop treatment resistant condition which, over time, may worsen, causing additional problems to already vulnerable patients (Zepinic, 2015).

War-related refugees are commonly wrestling with feelings of fear, despair, hopelessness, miserable status, guilt, devastation, inferiority, pessimism, tiredness, hurt, uselessness, insecurity, loneliness, isolation, uncertainty, vulnerability and rejection. They are often in a position of desperately searching for safety, trust, healing their psychological wounds and experiencing minimum respect as human beings. It is about individuals who had been confronted with the evil experience which troubled their lives and forced them to leave living place albeit knowing they are going to an unknown place with no clear prospects and with a lot of uncertainties for their future.

In the new surroundings, the refugees face another culture, language, norms, customs and values; all indifferent to their destitute lives, identity loss, psychological and/or physical wounds and personality changes. They also face disparities in ways of life and in employment opportunities—refugees are more unlikely to have skills and knowledge that could be easily transferable to their new adopted country. Thus, a great deal of research has focused on understanding an immense transition and the factors which could contribute to the unsuccessful or successful promotion of a new life and well-being (Ager, 1999; Bentovim, 1992; De Jong, et. al., 2005; De Zulueta, 1993; Papadopoulos, 2002; Wilson, 2004; Zepinic, et. al., 2012). It is almost universal that great parts of the refugees had experienced trauma which included combat, loss of relatives and friends, torture, witnessing other people killed or severely wounded, persecution through ethnic cleansing, rape, being shot at and wounded (Zepinic, 1997).

There is extensive literature documenting that traumatic experience leads to a severe and long-lasting psychological distress which is associated with impaired social functioning and disrupted quality of the life. Forceful migration usually poses an on-going traumatic situation and tends to cause more complex trauma syndrome and difficulties to cure sustained trauma-related disorders and dysfunctions. Thus, numerous publications have shown that the complex PTSD is not simple mental sequel of the severe traumatic experience but also accompanied with other disorders such as depression, anxiety and personality changes.

It is worthy to note the need to consider other trauma-related disorders, including personality disorders, or some psychosis. Also, some refugees do not even fulfil criteria for PTSD or other stress-related disorders, but can still be very disruptive and overwhelmed by severe and long-term distress.

Researchers revealed that the most refugees exposed to the traumatic experience (although migration itself is traumatic too), particularly after the exposure to repeated and an on-going stressful event(s), develop persistent trauma syndrome (treatment resistant) that can last for decades (Ayalon, 1998; Bremner, et. al., 1997; Briere, et. al., 2005; Cloitre, et. al., 2009; Courtois, et. al., 2009; Foa, et. al., 1998; Herman 1992; Horowitz, 1978; van der Hart, et. al., 1993; van der Kolk, et. al., 1996; Wilson, 2006; Zepinic, 2004, 2012). In refugees, we often face with an accumulative trauma as a product of series of the traumatic and non-traumatic experiences accumulated over the time within interaction of the individuals with their past and new circumstances of settlement and these may lead to serious mental problems.

Different factors and the interactive relationship between an individual and his surroundings converted the events into the process of a sequential traumatisation. The traumatic event(s) usually changes environmental and personal context of one’s interact with the traumatic experience through time that causes the quality and quantity of the traumatic sequences to be different in various contexts and, at different time, across the trauma victim’s lifespan. In those forcefully displaced refugees, it is common development of a severe (complex) PTSD with comorbid conditions of very complex post-traumatic symptomatology characterised by dimensions of the continuum of pathological reactions to the trauma (Resick, et. al., 2012; van der Kolk, et. al., 1996; Wilson & Drozdek, 2004; Zepinic, 2012).

According to numerous studies, the problem with severely traumatised individuals is that they present psychological or intrapsychic, also medical, social, political, cultural, existential or multidimensional sequalae. Mental health professionals or caretakers