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When Complex Trauma & Severe Character Pathology Meet Part 2

Exploring treatment options and clinical considerations.

Key points

  • Complex childhood trauma with severe personality disorders require many years of treatment, often utilizing various approaches.
  • A re-enactment of the childhood trauma occurs in the therapeutic dyad.
  • Relational and other psychodynamic therapists believe healing is possible when certain conditions are met.

Empathy, and its precursor compassion, are qualities, not skills. They cannot be taught, but instead learned through relational interactions and exposure over time. An empathic environment is created and cultivated through receiving attuned and empathic parenting or having benefitted from healing through therapy. Self-empathy is the result, and the capacity to have empathy for others is a natural outcrop.

The therapeutic process is an opportunity for repair, which is certainly possible for patients with complex trauma histories. Nevertheless, unfortunately, the path to getting to a place of empathy for these individuals is generally never linear, predictable, or can be found in an evidence-based treatment manual.

Motortion Films/Shutterstock
Source: Motortion Films/Shutterstock

Clinical Issues to Consider for Treatment

Patients who suffer complex childhood trauma and develop severe personality disorders require many years of treatment, often utilizing various approaches. Those with pathological narcissism and borderline pathology, in particular, maintain a pathologic grandiose self and typically create or engage in lifelong chaotic relationships. In addition, they idealize themselves and devalue those around them; their envy and low self-esteem dictate their behavior and combine with antisocial behavior, targeted aggressiveness, and paranoid traits (Mucci, p. 206.) These characterological attributes make it difficult for those in close relational orbit to trust them.

Patients with these personality disorders seek the admiration (not the love) of others. Manipulation and seduction are the general rules to achieve this aim. Their pathology necessitates skill, experience, and training by professionals who provide treatment. Clinicians ought to be well-versed in various clinical and theoretical modalities and know when to refer for other types of treatment, as integration and the change of therapeutic modalities are often necessary. Since these individuals often maintain the veneer of healthier functioning and can convince well-intended professionals for some time, the veneer eventually falls, and the characterological pathology emerges.

Due to the nature of severe pathology, treatment compliance and outcome vary by individual. Patients quit out of frustration with treatment protocols and boundaries. Sometimes, therapists fire patients for non-compliance with boundaries and appropriate treatment parameters or because they refuse the need for higher levels or additional layers of care, like inpatient treatment, intensive group treatment, or medication. Therapists should understand the plethora of theoretical modalities to influence how treatment proceeds or needs to be altered or integrated; they do not need to be trained in all treatment modalities but understand when to refer and what type of other treatment makes sense.

Treatment Approaches

Analytically-oriented therapists agree that insight-oriented (psychodynamic) and interpersonal models (i.e., Relational Psychoanalytic - see Kuchuck) are, in the long run, the treatments of choice for many patients, including those with complex trauma. However, readiness for these treatments is neither linear nor predictable

A patient's readiness to participate in long-term psychotherapy treatment implies that a patient can adhere to the boundaries and limitations imposed by an outpatient setting. Regression and dissociation are bound to occur; therapists need to feel secure that a patient can leave after a session and resume a functional life between sessions.

Because the denial of childhood trauma may remain strong while the underlying need to identify with the abuser may continue, the reenactment of the childhood trauma occurs in the therapeutic dyad, as the patient is determined to destabilize the treatment, recreate the trauma, and attempt to take control of feeling powerless as a child. An analytic frame arouses powerful reactions. Without an ego (the observable and moderating component of the human psyche), the potential for protracted dissociation is likely, and recreation of the trauma states in contemporary relationships is inevitable.

Dissociation can and will likely occur during sessions; the patient assigns the role to the therapist of either the victim, or, at times, the aggressor (the roles the patient experienced during childhood). The patient imbues the therapist with such roles (a process called "transference" in therapy). The therapist can use such enactments to emotionally contain and hold the patient through these states if the patient can maintain some self-awareness (ego and cognitive function.) These regressive states can then be understood, analyzed, and used for the patient to reflect on the underlying source of the trauma during their childhood. The patient must be able to observe and reflect on their history, in effect, to step out of the transference state to gather insight and ultimately repair their relationships with loved ones, including themselves.

When a patient demonstrates, through boundary crosses, unrealistic demands of the therapist's time, an inability to work within the implicit limitations of an outpatient setting, or regularly threatens suicide, either as a means to control the therapist or as an authentic outpouring of pain, other treatment methods must be employed.

As such, patients often require and often refuse higher levels of care. They usually go from therapist to therapist and may ultimately invalidate all therapists. Proper stabilization, like an intensive six-month course of residential or intensive outpatient Dialectical Behavior Therapy (DBT) treatment and medication, can often return patients to an analytic treatment, as their reactivity, impulsivity, boundary crossing, and inappropriate demands can be minimized or eliminated with such additional treatment.

Cognitive behavioral approaches and other stabilization therapies, like intensive DBT, can help with impulsivity, vengeful attacks, volatility, and mindfulness training (Lineman, 2014). Medication, like antidepressants, mood stabilizers, and generally low-dose antipsychotics, can also significantly aid mood dysregulation, delusions, and severe anxiety. Ongoing, long-term psychotherapy groups for complex trauma patients can be challenging, as envy and paranoia may emerge. On the other hand, identification, reflection, and the development of empathy for self and others are also possible.

Clinical Issues for Therapists

Therapists enter the field of mental health treatment for a variety of reasons. Often, the driving forces for therapists are to feel valuable and productive, make a positive contribution to others' lives, and offer hope and inspiration to people they meet along the way. In addition, some therapists seek a community of like-minded individuals who provide an emotionally safe space, honest and authentic communication, and whose professional and personal judgment is ethically sound and responsible. It is our hope, in this sense, to help our patients acquire and reach for a similar caliber in themselves and their relationships.

A crucial philosophical perspective of the Relationalists is that any analysis is potentially fraught with dialectical positions, that is, the struggle with "opposites." These include quandaries from what is "inner vs. outer" to "one-person vs. two-person psychology," to "intrapsychic vs. interpersonal," to "reality vs. fantasy," and so forth (Ringstrom, 2014).

Psychoanalytically-oriented therapists use the relationship as a core component to analyze conflict in the patient's life and create a stable environment to contain the patient's feelings while maintaining boundaries. Complex trauma patients require many years of treatment. In order to utilize an analytic and relational approach, they must work toward integrating the rageful and sadistic elements in their personality without destroying the therapeutic relationship. Without this, self-empathy cannot emerge, and the resultant capacity for trust and healing cannot occur.

When patients with complex trauma also have a borderline level of personality organization, or one of malignant narcissism (Kernberg, 1985), identity diffusion, primitive defenses, distortions, antisocial, paranoid, or aggressive features make these patients dangerous to themselves and others, including the therapist. "They are mostly aggressive and destructive against others but can be destructive against themselves in a calculated and often exhibitionist way," (Mucci, p.184).

Kernberg believed that those patients termed "malignantly narcissistic," are incapable of being helped. Relational and other psychodynamic therapists believe it is possible when certain conditions are met.

Read Part I of this post here.

To find a therapist near you, visit the Psychology Today Therapy Directory.


Kernberg. O. Borderline Conditions and Pathological Narcissism. (1985.) Lanham, MD: RRowman & Littlefield

Kuchuck. S. (2021.) The Relational revolution in psychoanalysis and psychotherapy. London, UK: Confer Books:

Lineman. M. (2014) DBT Skills Training Manual, Second Edition. New York: Guildford Press:

Mucci. C. (2018.) Borderline Bodies: Affect Regulation Therapy for Personality Disorders. NY & London: W.W. Norton & Company.

Ringstrom, P. (2014.) “Everything you’ve wanted to know about relational psychoanalysis but were too confused to ask.”

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