A new diagnosis of complex Post-traumatic Stress Disorder, PTSD – a window of opportunity for the treatment of patients in the NHS?

The concept of complex trauma has been around for a long time and in 2018, it’s expected to become a new diagnosis in the International Classification of Diseases eleventh revision, ICD-11, the World Health Organisation, WHO, manual used formally in the NHS. Psychiatric diagnosis often does not sit well with psychoanalysis, which is at least as interested in unconscious phantasy as it is in symptoms. But as psychodynamically-trained practitioners in the NHS we need to engage with ICD-11 and apply our own understanding to service design so that patients have access to treatment which works for them. The service where I work (a secondary mental health team in the London borough of Lewisham) has already been receiving referrals for ‘complex trauma’ for some time, despite its not being formally classified. Patients so described are most often those with a history of childhood sexual abuse, and refugees with a history of brutality and torture. Differential diagnosis includes personality disorder since many have difficulties with interpersonal issues. In this paper I want to discuss how we might understand the new diagnosis of complex Post-traumatic Stress Disorder, PTSD, and its implications for treatment in the NHS.


Freud and complex PTSD
In her seminal study of PTSD in 1992, Trauma and Recovery, Judith Herman begins by exploring how psychoanalysis grew out of the study of complex trauma. She describes Freud's early work with mainly female patients that focused on the origins of hysteria and how to cure it. In his report on 18 case studies, The Aetiology of Hysteria (1896), Freud theorised that 'premature sexual experience ' (p. 203) was behind every case of hysteria. But the theoretical paths of complex trauma and psychoanalysis soon diverged with Freud revising his theory that real sexual trauma was behind hysterical symptoms. Thus began the privileging of the internal world for which psychoanalysis has often been criticised. In this paper I will argue that the new diagnosis of complex PTSD offers a window of opportunity for psychodynamic practitioners to build on these theoretical origins, by incorporating later theoretical developments in the psychodynamic field around attachment theory. The intention is to explore more progressive forms of treatment for patients whose problems may fit the new diagnosis.

The opportunity of ICD-11
The ICD manual, which was last revised in 1992, has important implications for the allocation of resources in the NHS. The ICD defines the diagnoses, and in the UK, the National Institute for Health and Care Excellence, NICE, recommends treatments based on these diagnoses. For the first time ever, the ICD is set to include complex PTSD (WHO, 2012), which means there is an opening to develop and provide evidence for new treatment approaches.
The new diagnosis may be seen as a recognition of the aetiology and symptoms with which Freud was concerned when he began his work on hysteria. Both before and after Freud, clinicians have struggled with the same challenge of how to help patients seeking help for symptoms which centre on re-experiencing in the present traumatic events of the sometimes long distant, or even forgotten, past. Many clinicians concur that it was clinically useful in 1980 (American Psychiatric Association) to formulate a diagnosis of what I will call 'core' PTSD, which might include, for instance, someone who had experienced a traffic accident or a natural disaster such as flooding. But clinicians have found that the evidence-based treatments developed for 'core' PTSD are not always helpful to patients with more complex problems. In my experience this typically includes those with a history of abuse, violence and/or torture. This is why the new diagnosis of complex PTSD has been developed.
The ICD-11 complex PTSD diagnosis has to include the core symptoms of PTSD itself and therefore I will first look at 'core' PTSD and some of the criticisms levelled at it. I will then outline the concept of complex PTSD in the new ICD-11. The different path taken by the US classification manual, Diagnostic and Statistical Manual of Mental Disorders, DSM-V, will not be covered here. I will look at some of the treatments offered in the NHS for PTSD so far. I will then look at differential diagnosis and how some patients whose symptoms match some of those in complex PTSD may have been diagnosed with a personality disorder. I will briefly mention some of the literature on attachment, group therapy and PTSD which suggests that group work may be an effective treatment for complex PTSD. I will give some clinical examples of treatment I have carried out myself with groups, with some preliminary findings of evidence for efficacy. Psychoanalytic Psychotherapy

The difference between 'core' PTSD and complex PTSD
The psychiatric theory underlying the diagnosis of Post-traumatic Stress Disorder, PTSD, is that real events in the outside world caused the patient's symptoms. Originally this was the theory that Freud extrapolated in his early work, whereas later he focused on unconscious mental processes. In fact, research into the aetiology of PTSD suggests that the problem lies in the interaction between internal and external worlds: people with similar traumatic experiences do not all develop symptoms (Young, 1997). However, it is important to recognise that without a traumatic experience PTSD does not develop, because this has implications for what kind of treatment may be useful.
The first criterion for complex PTSD provisionally agreed for ICD-11 is: Exposure to a stressor event typically of an extreme or prolonged nature and from which escape is difficult or impossible such as torture, concentration camps, slavery, genocide or other forms of organized violence, domestic violence and childhood sexual or physical abuse. This is the wording agreed by the Working Group on stress-related disorders for the revision of ICD-10 in 2012 (WHO, 2012), which is likely to be approved in 2018. The diagnosis is predicated on: 'the core symptoms of PTSD (re-experiencing the trauma in the present, avoidance of reminders of the trauma, and persistent perceptions of current threat).' The new guidelines include: 'the development of persistent and pervasive impairments in affective, self and relational functioning, including difficulties in emotional regulation, beliefs about oneself as diminished, defeated or worthless, and difficulties in sustaining relationships' (WHO, 2012, p. 2). It is these last three criteria which really define complex PTSD and it is clear that such difficulties are likely to make any treatment a challenge.

History of PTSD
The diagnosis of 'core' PTSD itself is a relatively recent inclusion in psychiatric manuals, appearing for the first time in 1980 (American Psychiatric Association), and was a response to the difficulties presented by veterans returning from the Vietnam war. In fact, writers as far back as ancient Greece have described PTSD symptoms (Shay, 1991), and the origins of current ideas about psychological trauma in Europe can be seen from the late-nineteenth century in the work of Janet (cited by Van der Kolk, 2007) and others, as well as Freud. Freud, of course, changed his mind about sexual abuse being more than a fantasy in most cases, and instead developed a powerful theoretical framework about the internal world. But he and others continued to write about the diagnosis of 'traumatic neurosis' (Freud, 1917, p. 274) and in the First World PTSD symptoms came to be described as 'shell-shock' (cited in Herman, 1992, p. 20). The work of US psychiatrist, Abram Kardiner, in his 1941 book, The Traumatic Neuroses of War, then formed the basis for present-day clinical work on PTSD (cited in Herman, 1992).
In the UK, war psychiatrists such as Bion worked with veterans in groups to rehabilitate them from what he called 'neurosis' (Bion,1961, p. 18). Herman goes on to describe how social movements in the US made up of returning Vietnam veterans, as well as the women's movement, stimulated clinicians into working on the psychological consequences of trauma, both war-time trauma, and the trauma of domestic violence, rape and abuse (1992).

PTSD as a social construct
The significance of such political and social factors in the evolution of the PTSD diagnosis has led some critics (such as Fassin & Rechtman, 2009;Young, 1997) to see it as a social construct elaborated to justify a narrative of victimhood and bolster political, financial and other demands from sufferers identifying themselves as injured parties, and their supporters. Other critics who include some with extensive experience of working in non-European cultures have suggested that the diagnosis promotes an intra-psychic and individualistic approach to healing, which excludes vital social and political dimensions (Blackwell, 2009;Bracken, 2001). Still others see PTSD as the medicalisation of a normal human response to horrific events which might in the past have been dealt with by non-medical means such as family and community support (Summerfield, 2001). Although these critics call into question the validity of the PTSD diagnosis, many clinicians (Friedman, Resick, & Keane, 2007) find the diagnosis useful in the consulting room to conceptualise patients' difficulties, such as vivid flashbacks and nightmares, and to formulate effective treatment approaches. Moreover, recent developments in neuroscience have made visible to us what goes on in the brain to cause PTSD symptoms and I will expand on this now.

Current treatments for PTSD and the neuroscience evidence
Modern techniques for observing and identifying activity in the brain, such as functional Magnetic Resonance Imaging, fMRI, show how traumatic events have physiological effects (Lanius, Vermetten, & Pain, 2010). They show how life-threatening or terrifying experiences activate the amygdala, which enables rapid involuntary responses to boost survival. But this bypasses the hippocampus which usually processes memories cognitively into a coherent narrative. This means the trauma gets 'fixed in the mind' as Van der Kolk (2000, p. 245) puts it, with the traumatic events stored in a fragmentary way and still connected up to the survival-based bodily responses such as hypervigilance. This is why current treatments recommended by NICE for PTSD (NICE, 2005) which are Cognitive Behavioural Therapy, CBT, and Eye Movement Desensitisation and Reprocessing, EMDR, involve unblocking the trauma through exposure or processing the trauma while orienting to present safety. Trauma-focused CBT aims at this, while Psychoanalytic Psychotherapy EMDR (Shapiro, 2001) may not involve talking directly about the trauma, but does involve visualising the worst of the traumatic events while undergoing bilateral stimulation. EMDR may include moving the eyes from left to right, listening to sound alternating in right and left ears, or tapping on right and left knees.
It must be noted here that neuroscience also demonstrates a less common neurobiological response to trauma, a disruption in consciousness or dissociation , which may include numbness, freezing and depersonalisation. This involves overmodulation of affect, rather than undermodulation, and some authors (Schmahl, Lanius, Pain, & Vermetten, 2010) suggest they are sequential stages which can also be seen in animal defensive behaviour. Patients experiencing these symptoms may not be helped by exposure-based therapies.

Treating PTSD in the 'real world'
This leads me directly to the clinical problem which a new diagnosis of complex trauma was intended to address: that many clinicians such as Van der Kolk (2000) or Lab, who worked at the Traumatic Stress Clinic at the Maudsley Hospital in London, have found that treatments for which there is a statistical evidence base are not always successful in the 'real world' (Lab, Santos, & de Zulueta, 2008, p. 1). The patients to whom this applies have the symptoms included in the new diagnosis of complex trauma: inability to regulate emotions, difficulties in relationships with other people, and negative feelings about themselves, particularly shame, guilt and worthlessness. This is where theories about the internal world come in.

PTSD and the internal world
Attachment theory, while rooted in biology, gives a more intra-psychic explanation of how patients may develop such symptoms. Damaging experiences in childhood lead to Internal Working Models which are then replicated in future relationships, and lead to emotional vulnerability (Bowlby, 1969). Early failures to help infants manage their emotions are likely to lead to emotional dysregulation later in life. Some clinicians such as De Zulueta (1993Zulueta ( /2006 have suggested that the disorganised style of attachment, often seen in such patients, might be renamed traumatic attachment so as to describe more accurately both origins and current experiences of attachment suffered by those with these symptoms. Neuroscience even demonstrates how early developmental deficits in nurturing cause changes to the brain, which can incapacitate people in these areas of mental life (Gerhardt, 2004). Knox (2013) also describes how neurobiological responses to the experience of powerlessness in early trauma can lead to overwhelming shame and self-blame which are highly resistant to change.
Refugees diagnosed with complex PTSD may not have early developmental deficits, but have had equally damaging experiences of relationships with others so as to change catastrophically their view of themselves, other people and the wider world. This was well described by CBT pioneer Anke Ehlers (Ehlers, Maercker, & Boos, 2000, p. 45) as 'mental defeat', 'a state of giving up in one's own mind all efforts to retain one's identity as a human being with a will of one's own.' Such patients often experience the shame, guilt and worthlessness experienced by those who have suffered developmental trauma. A psychoanalytic perspective is useful here in indicating how a real event in the external world may combine with unconscious phantasy about primitive destructiveness in a self-fulfilling vicious circle (Garland, 1998). Thus, a patient who has unconscious fears of their own and others' murderous instincts may have these unfortunately confirmed in the external world with catastrophic mental consequences.

The overlap with borderline personality disorder
If we theorise complex PTSD as a breakdown in the attachment system, with concomitant interpersonal difficulties, what kind of treatment might be useful?
There may be some clues from current treatments for borderline personality disorder, BPD, because of the similarity in symptoms with complex PTSD (De Zulueta, 2009). Current treatments for BPD offered in the NHS include Mentalisation-based therapy, MBT, and Dialectical Behaviour Therapy, DBT, both of which aim to help patients with affect regulation, inter-personal relationships, and negative self-image.
DBT in particular with its emphasis on teaching skills to cope with affect regulation could be considered as the stabilisation phase recommended for complex trauma by the Expert Consensus Treatment Guidelines of the International Society for Traumatic Stress Studies (Cloitre et al., 2012). The guidelines were drawn up by expert clinicians who had formed a Complex Trauma Task force. They recommend a phase-based approach where stabilisation establishes a secure base from which to undergo trauma-focused therapy, which is followed by reintegration into the community and recovery. Although the usefulness of the stabilisation phase has recently been questioned (De Jongh et al., 2016), more research is needed. It is also relevant to note that a lack of social support is one of the most significant risk factors for developing PTSD as mentioned in the NICE full guideline (National Collaborating Centre for Mental Health [NCCMH], 2005, p. 96)

Current pressures on the NHS
Here I want to return to the critical writers cited above (Bracken, 2001;Summerfield, 2001) who are concerned about the way in which psychological distress has been medicalised through the PTSD diagnosis, partly because important social and political dimensions of suffering may be ignored in individual treatment by clinical experts. Another negative consequence of the 'medicalisation of distress' may be a greater burden on the NHS, and indeed, increasingly complex presentations have been noted by some of the clinicians who bear this burden. This was seen in a 2014 survey of 2026 psychotherapists, who were members of the British Psychoanalytic Council, BPC, or the UK Association of Counselling and Psychotherapy, UKCP, which showed that 77% of them had experienced an increase in clients with complex needs (BPC/UKCP report, 2014). The survey also found that 29% of them said their caseload was up on the previous year. Bracken (2001) suggests that social fragmentation and the decline of social institutions are contributory factors to a generalised increase in trauma, which he defines as a breakdown in meaning. One result of such a decline in social institutions could be that the NHS may be seen as the carer-of-last-resort.

Rationale for group treatment
I am therefore arguing that there are both clinical and practical reasons to look for and evaluate new treatment approaches for complex PTSD. The clinical factors are that there are patients presenting with complex trauma for whom current treatments are problematic because of their symptoms, and for whom addressing social aspects of their situation could be helpful. The two types of patients who commonly present with the ICD-11 diagnosis, both tortured and abused patients, have experienced a breakdown in social relationships which needs to be repaired for their recovery. Practical factors include the increasing numbers of patients seeking secondary mental health services in a context of government cuts to NHS funding (Gilburt, 2015). These are the factors which led us to consider the role of groups and the possibilities of peer support in promoting recovery.

Literature on groups for PTSD
The literature from both group therapy and PTSD fields supports such treatment. One of the founders of group therapy, Yalom (Yalom & Leszcz, 2005) describes how groups can provide therapeutic factors such as universality, which is the recognition of shared experiences and feelings among members. This is therapeutic for those with complex trauma because it serves to remove a sense of social isolation, reduces shame and raises self-esteem, as will be seen in the clinical vignettes below. Other useful studies from group therapy are Kanas (2005), Seager and Thummel (2009), and Valerio and Lepper (2009). Literature from the PTSD field distinguishes between groups which focus on symptom management or stabilisation, and those which involve trauma disclosure. They include Classen, Koopman, Nevill-Manning, and Spiegel (2001), Cloitre et al. (2010), Courtois (2008), and Fallot and Harris (2002). A helpful survey is done in Courtois and Ford (2014, pp. 415-440). In our service we are implementing two different group modalities for patients with complex trauma, one of which focuses on current symptoms and emotions, while the other includes trauma processing. This is because patients who are asylum seekers may not feel safe in the UK while at risk of deportation, and therefore trauma processing may re-traumatise them.

Asylum seekers' group
This group is a combination of social support, horticultural, and therapeutic treatment for Sri Lankan Tamil asylum seekers, designed and run with a local community organisation. Literature on the therapeutic value of gardening and psycho-educational groups includes Linden and Grut (2002), and Clatworthy, Hinds, and Camic (2013). There is also useful evidence of efficacy from a small-scale evaluation done by researchers in the interdisciplinary Centre for Environment and Society at Essex University of Vauxhall City Farm project, which has been run by the same NHS Trust for a number of years (Hine, Barton, & Pretty, 2009).
There is a particular concentration of Sri Lankans in the borough of Lewisham and in the last three-and-a-half years, 64 Sri Lankan Tamils have been referred for secondary mental health treatment for PTSD (September 2012-March 2016). The Tamil community in Sri Lanka has been persecuted by the Sinhalese majority government for many years and all referrals were asylum seekers or refugees. Fifty-seven out of the 64 were men. A few were granted permission to stay in the UK before or during treatment but most are still waiting for the resolution of their cases. They have fled their homeland following detention and brutal treatment by the government, and some have long histories of war-time trauma as children, including displacement and shelling. This is clinically relevant because the lack of current safety indicates that exposure-based treatments could be re-traumatising, and even unethical. There are also other factors likely to aggravate mental vulnerability, such as being unable to work in the UK and uncertainty about where their future lies. No differentiation was made by referrers between PTSD and complex trauma, but on assessment we found that the additional criteria for complex trauma were prevalent. In total 39 patients have attended the group since it began in July 2014.
The group meets weekly at a community garden site and includes one hour of horticultural activities, and a one-hour long talking group. We hold the talking group in a huge greenhouse with a log-burning stove if cold, and outside under the shade of trees if warm. A Tamil interpreter attends for the talking group that includes psycho-education in which contributions from group members are used. The presence of a peer support worker from the UK has been invaluable. The topics include: coping with flashbacks, anxiety, depression, anger, sleep problems including nightmares, and how it feels to be living in the UK. Social isolation, missing family, language difficulties, and being dependent on others are also issues that often concern members. The group runs for 20 sessions and then members are able to join a bigger group run by the community project, which includes a group lunch. Members themselves play a leading role in this group which has constructed a giant plastic greenhouse, a polytunnel, since Easter 2015. One group member is a skilled carpenter and has masterminded the building work, while a number of others have construction skills. Working together on a task can be a more healing experience than talking about the traumatic events. The objective of this second stage is to promote reintegration into the community through breaking down social isolation and facilitating the formation of a peer support group. Three participative evaluations have been held at the end of each 20-session group, and some details will be given below. I include here a vignette of my recent experience of running the group on a freezing cold day in early spring. Confidentiality has been preserved by disguising individual details.
On my arrival at the garden site, one patient, wearing a smart leather jacket, is standing on a bent tree branch while another saws the trunk. The one on the branch jumps down lithely while three others pull on a rope, and after a few minutes the trunk gives with a loud crack. They all grin with satisfaction and go off to wash before group, which is held in a large greenhouse.

Therapist:
How did the gardening work go today? A: Well, it was good cutting down that tree, we all had to work together as a team. Therapist: Yes, I saw that. It looked quite difficult. A. says: Oh no, we used to cut down trees all the time at home for bunkers.
(Group all laugh.) Therapist: Oh? B: Yes, when the army was coming after us we dug trenches and put branches over them for roofs. Therapist: What, all of you did that? Group chorus: Oh yes (laugh again) Therapist: OK, let's go on to how you are this week. What about you, C, how have you been? C: I wasn't too good really, I had a phone call with my family. They're in hiding and the kids can't go to school any more. My little boy, he's 6, he kept asking me why I don't come home. My brother-inlaw took the phone and told him that I was on the bus and it had broken down. He was making a joke. Therapist: You don't feel able to tell your son where you are? C: No, the police have asked the children where I am and if they find out I'm in London they'll be in more danger. Therapist: That's really hard … D: I had to report to the Home Office, we waited in a queue for 4 hours and it was freezing. Then they took me to a room inside for questioning, I felt scared, and like I was a thief. Before I came here, I had a good job in accountancy … I don't want to be this person I am now … The group ends with psycho-education and a practical demonstration of techniques to manage PTSD symptoms, such as imagining a Safe Place, muscle relaxation or breathing. We have found that a practical ending provides necessary emotional containment in a group where despair, frustration, fear and sadness abound.

Methodology and preliminary findings-asylum group
All group members are asked to complete a self-report questionnaire, which quantifies mental health problems over the previous week, at the beginning and end of the 20 session group as a minimum. This is the Clinical Outcomes in Routine Evaluation, CORE, which has been translated into Tamil. There are difficulties with interpreting the results from the CORE, partly because group members know their NHS records can be requested for use in their immigration case. An applicant for asylum may have more chance of getting refugee status if there are mental health difficulties such as PTSD. We have also noticed that sometimes the most significant factor affecting CORE scores is what is happening with the Home Office. Of the 27 paired CORES received to date, 14 patients had similar scores or had improved, while 13 were worse. Focus groups have been held at the end of each group to enable qualitative evaluation and this has provided more useful details of what patients found helpful or not. I include here a comment made in a focus group at the end of 20 sessions in July 2015: I used to be frightened to talk in a large group but everyone is in the same boat so I feel I can say more. It's difficult when you have these problems, if you talk about it, sometimes people think you are crazy, so it's good to talk to others who have the same experiences. When we discuss about how we feel, you all tell me not to harm myself and not to think about suicide and that helps me. After leaving here, I think about what we did and so I don't have time to think about the past.
The comment above shows that the group has a function as a secure base for young men whose support network has been lost. This is seen in the words 'everyone is in the same boat' and 'it's good to talk to others who have the same experiences', illustrating the universality described by Yalom and Leszcz (2005). Similar views have been expressed in each of the evaluation sessions we have held with the three groups. The most painful experience for many of them is the loss of identity as aspiring and ambitious young men, as is suggested by the member above: 'I don't want to be this person I am now.' While the horticultural activity does provide a physically healthy exercise and therefore promotes mental health, its main role is to enable them to be effective in achieving a challenging piece of physical work with others. Relating in their own language to others in a similar situation also breaks down the social isolation that intensifies emotional vulnerability.
While refugees suffering from complex trauma usually do not have the early attachment difficulties suffered by abused patients, they often present with marked difficulties around shame, guilt and feelings of worthlessness, as well as mistrust and suspicion of others. As the interaction and feedback above suggest, working together as a group on a shared task promotes a sense of achievement and self-worth, which is invaluable therapeutically. It is interesting to compare this with the way Bion (1961) organised his rehabilitation unit in Northfield after the Second World War. Psychoanalytic Psychotherapy

Women's group
A number of clinicians in the US have devised treatment approaches for complex trauma based on group work, that involve both stabilisation and trauma-focused work, such as Cloitre et al. (2010) and Harris (1998). All have a structured framework, and Harris in particular includes family and social dynamics, such as the power differential between men and women, as well as individual issues.
We decided to use a model, informed by attachment theory, that is described by Canadian psychiatrist, Philip Ney in his book entitled 'Ending the cycle of abuse' (Ney & Peters, 1995). He led a therapy group during which group members were guided to grieve for what they had lost, including their own childhood, and then find a way forward. We ran a group of 35 sessions in 2015-2016 adapted from Ney's model for women who had experienced sexual abuse in childhood. We included psycho-education to help with emotional regulation and practical techniques to cope with PTSD symptoms. Patients were set weekly homework tasks, which they considered during the week, and then discussed at group. The programme progresses through emotional stages including Realisation, Despair, Guilt, Anger, Mourning, Reconciliation and Rehabilitation. It particularly helps patients to consider the dynamics of relationships with family, who may include the abuser, as well as an observer who failed to protect the child.
The patients came from a variety of cultural backgrounds: Middle Eastern heritage born in London, British Bangladeshi, white British, mixed race Nigerian, Indian and Irish, and black southern African background. All had experienced sexual abuse from family members, most from a very young age. Some had also experienced extreme poverty and emotional neglect. An evaluation is not yet complete as we are waiting for results from a second group so that we have a larger number. The vignettes below give a preliminary indication of patients' experience of the group. All have given signed consent to the use of material from the group and the recording of the focus group afterwards.
The following extract is from a group where the women were talking about their mothers:

Methodology and preliminary findings-women's group
The focus group which followed was held one week after the group ended in the same location with an external facilitator. Group members were asked what they had found helpful and this was one of the responses: X: I think the stuff about my mum … I don't know if it was helpful, well it was useful in the fact that I know it's not just me that hates my mum undyingly, that was very useful. Facilitator: OK, so that's something happened there that was useful. X: Yeah it was very useful but then you're also telling me that I now have to see this woman on Sunday for Sunday dinner. I don't want to see her after I've been talking about all these things. I don't … it kinda made me hate her a little bit more … but it made me hate myself less. Facilitator: OK, well, that's interesting X: Yeah, maybe allocating blame, yeah, maybe I expected more from my mother because I've heard her mum was dodgy … her mum was dodgy … and Y. and Z.'s mum was also dodgy … we all have different feelings about our mums but it was nice to be able to congregate and talk about it in a more poignant way … Women attending this group had long-standing attachment difficulties, particularly with their mothers, as the extracts above illustrate. The first extract shows women sharing the pain of their mothers' abandonment and neglect with each other. There are some signs of coming to terms with it in the way that two of them recognise that their mothers had their own difficulties (one was married at 13 years, and another was working all hours as a cleaner.) In the extract from the focus group, the patient says she hated her mother more after talking about her in group, but hated herself less. She also feels it gave her some relief to talk, as well as listen to others' experience of 'dodgy' mothers. Preliminary finding from focus group feedback was mixed. Some members felt that too much had been asked of them emotionally, and that more systematic stabilisation input, as well as emotional support outside the group, would have helped them attend the group more regularly.
As well as the women's group described above, we have run a second women's group subsequently and are awaiting the outcome so as to have numbers for statistical significance. Quantitative methodology has included two self-report questionnaires done pre-and post-group. One was the CORE-OM, and the other an Adult Attachment questionnaire (Collins, 1996), which asks group members about their attachment difficulties. Qualitative analysis will be done on two focus groups held at the end of the therapy groups.

Conclusions
Further research needed I have described two pilot projects involving group work for patients with complex trauma, and both need outcome evaluation to provide an evidence base. The asylum seekers' group has proved difficult to evaluate quantitatively because of their precarious immigration status. Not only is it in their interests to have a diagnosis of PTSD, but their mental health continues to be badly affected by dealings with the Home Office. Further research in needed in how to manage this, not only in terms of rigorous evaluation, but also in order to consider more practical support. Qualitative methodology has provided more useful feedback and will be analysed systematically.

Caveat
We have to acknowledge that there may be some patients with complex PTSD for whom talking therapies (even in the groups described above) may not bring recovery. For instance, sensorimotor techniques may be a vital prelude or even the only useful treatment for some of those who experience dissociation. It is also necessary to say that there are patients who may not recover from the losses they have suffered. These include a woman from Kosovo held in a Serbian prison whose daughter and parents are still missing, and a woman from Rwanda whose husband and 3 children were killed in the genocide. For these patients, medication is likely to be an option, perhaps with psychosocial interventions. As Blackwell (2009) points out, it may be disrespectful and even dehumanising to expect that any psychotherapy could provide a quick fix for the emotional damage and loss resulting from such catastrophic events

Summary
Current NICE guidelines on the treatment of PTSD are limited to CBT and EMDR. Although the new diagnosis of complex PTSD includes the criteria for core PTSD, there are questions for some clinicians about whether treatment can or should be the same. Complex PTSD often follows life events from which it is difficult to recover, given that they involve such major losses in both internal and external worlds. I have suggested that group models could be a way forward for complex trauma, and I have described two such models which have roots in psychodynamic theory on attachment, as well as group therapy. Early patient feedback has also highlighted the significance of social interaction with peers in the groups in reducing their emotional suffering, reducing shame and enabling new insights. In a social and political context where the NHS may be the 'carerof-last-resort' while struggling with fewer resources, group work can capitalise on the strengths of peer support.
Psychodynamic practitioners are well placed to take forward treatment approaches which recognise, as Freud originally did, that it was traumatic interactions with other people which had a catastrophic effect on mental health. Attachment theory focuses on healthy relationships, as well as damaged ones, and shows how real relationships in the external world can also be a path to repairing the internal world.