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Counseling Skills for the Treatment of Complex Trauma


1. Experts believe that there needs to be an increase in the provision of psychotherapy and counseling for survivors of sexual violence and complex trauma, as existing services don't always incorporate full exploration of the dynamics involved in complex trauma.

A. True

B. False

Part 1: Understanding Trauma and Complex Trauma

2. In contrast to a single traumatic event, the repeated betrayal of trust, in which abuse masquerades as protection or affection, gives rise to a range of symptoms such as dissociation, alterations in sense of self, and:

A. Difficulties in daily functioning

B. Social impairments

C. Inability to care for oneself or others

D. A fear or intimacy in relationships

Complex Trauma Symptoms

3. Each of the following is an accurate statement about complex trauma EXCEPT:

A. Complex trauma reactions are commonly seen in people who have experienced prolonged sexual or physical abuse, or torture, especially if accompanied by deception

B. It is different that PTSD in that complex trauma elicits overwhelming, out-of-control physiological reactions

C. It impacts how survivors think about themselves and others, how they feel about their bodies, and how they relate to others

D. Complex trauma can result in the distortion of reality and a deep sense of shame

Section 2: Understanding Trauma Symptoms-The Alarm System

4. When the body's alarm system is tripped and goes on red alert, the parasympathetic nervous system mobilizes high level energy necessary for flight or flight, while the sympathetic nervous system slows down the heart and metabolic rate which results in the freeze response.

A. True

B. False

Role of the Freeze Response

5. In most cases of complex trauma, especially when it occurs in childhood, the general response is to run away from the threat.

A. True

B. False

Post-Traumatic Stress Symptoms-Avoidance

6. Some major post-traumatic stress reactions occur largely due to avoidance or lack of __________________,  which impedes emotional processing and prevents feelings from becoming fully integrated.

A. Reflective functioning

B. Contemplative actions

C. Deliberate behaviors

D. Meditative achievements

Section 3: Skills to Manage Complex Trauma Symptoms

7. Which of the following is NOT a likely bodily sensation that occurs with dissociation?

A. A sense of floating away

B. Looking at the self from a distance

C. Detaching from experiences through daydreaming or by being on auto-pilot

D. A sense of floating away

Clinical Dissociation

8. The type of dissociation that is associated with with severe childhood trauma and complex trauma in which distinct ego-states emerge to contain the traumatic experience is:

A. Tertiary dissociation

B. Primary dissociation

C. Secondary dissociation

D. Peritraumatic dissociation

Box 3.2 Dissociative Disorders

9. According to the DSM-V, generalized dissociative disorder is characterized by an inability to recall autobiographical information or life events.

A. True

B. False

Associated Disorders

10. Severe and chronic dissociation can lead to a range of associated disorders, most notably

A. Mood disorders such as depression and anxiety

B. Somatoform disorders and personality disorders

C. Substance-related and addictive disorders

D. Obsessive-compulsive and related disorders

Section 4: Understanding the Role of Attachment-The Function of Attachment

11. Early attachment bonds facilitate the regulation of emotions, and help the infant to learn that unbearable states can be managed.

A. True

B. False

Attachment Styles

12. The five primary attachment styles include each of the following EXCEPT:

A. Secure and anxious-preoccupied

B. Dismissive-avoidant and fearful-avoidant

C. Ambivalent and dependent-insecure

D. Disorganized/disoriented/dissociated

Traumatic Bonding

13. In order for traumatic bonding to occur, there has to be an imbalance of power in a relationship and the abuse must be constant and consistent.

A. True

B. False

Part 2-Section 5: Safe Trauma Therapy-Assessment

14. Generally speaking, survivors of complex trauma tend to benefit more from a warm, genuinely engaged, human relationship than a distant or clinical one which is driven by standardized protocols and assessments.

A. True

B. False

The Role of Psychoeducation

15. Psychoeducation is an important part of recovery, as ___________________ can help to stabilize trauma reactions in order to acquire the necessary skills to have more choice over emotional and behavioral responses.

A. Knowledge and reflection

B. Guidance and direction

C. Enlightenment and preparation

D. Information and discipline

Create a Safe Therapeutic Setting

16. With trauma survivors, practitioners need to be aware of personal space and create an optimal space which is not intrusive or invasive, and not too distanced.

A. True

B. False

Duration of Therapy

17. While survivors will vary in terms of length of therapeutic interventions, most benefit from a minimum of _______ of psychological support.

A. 6 months

B. 1year

C. 18 months

D. 2 years

Section 6: Therapeutic Challenges-Challenges in the Therapeutic Process

18. Which of the following is NOT a correct statement about empathy in the therapeutic process with survivors?

A. Many survivors will react strongly to highly empathic responses as they are not familiar with such empathy, or because they associate it with enticement by the abuser

B. Professionals will need to regulate the expression of empathy throughout the therapeutic process rather than with each individual session

C. While too much empathy can feel intrusive, too little empathy can be experienced as cold and clinical

D. Counselors will need to be mindful of not being overly empathic as this can make survivors feel extremely uncomfortable or suspicious

Core Challenges to Counselors

19. At times, professionals may feel anger, rage, and terror when hearing of brutality and dehumanization, and if these responses are not regulated, the professional may develop burnout and symptoms of vicarious traumaitization.

A. True

B. False

Section 7: Building and Maintaining the Therapeutic Relationship-The Role of the Therapeutic Relationship

20. In order to counteract damaged early relationships, counselors must provide a reparative, _________________ relationship in which they present what was missing in childhood.

A. Legitimate and valid

B. Positive and whole

C. Corrective and replenishing

D. Reverent and gracious

Barriers to Building the Therapeutic Relationship

21. The biggest obstacles in building the therapeutic relationship are fear of vulnerability, fear of disclosure, and fear of becoming defenseless.

A. True

B. False

The Role of Attachement Style in the Therapeutic Relationship

22. The attachment style most associated with complex trauma is the:

A. Disorganized attachment style

B. Anxious-avoidant attachment style

C. Anxious-preoccupies attachment style

D. Disconnected attachment style

Core Challenges in Maintaining the Therapeutic Relationship-Submission and Compliance

23. Submissive and compliant survivors tend to be overly-charming or tend to shift the focus of attention away from themselves onto the counselor in an attempt to be the "perfect client".

A. True

B. False

Section 8: THe Process of Recovery-Regaining Control

24. Research has found that control and __________________ are the two most positive factors in recovery from trauma.

A. A sense of purpose

B. Being able to maintain emotions

C. Success in relationships

D. Setting and achieving goals

25. During the process of recovery, each of the following is recommended EXCEPT:

A. Help clients pace their recovery by breaking it down into small, manageable steps

B. Encourage clients to celebrate their achievements and intoduce pleasure into their lives

C. Work with survivors to let go of negative cues from the past

D. Remind clients that they need to be aware of and embrace their past, as it will always dictate the present and influence the choices they make

Change is Difficult

26. Sometimes survivors experience an obstacle known as besmirchment, where they believe they are damaged goods and that they do not deserve a better life.

A. True

B. False

Part 3: Section 9: Establishing Safety and Control-Regulating Emotions

27. Exercise and grounding techniques can be especially beneficial to help survivors reconnect to their bodies.

A. True

B. False

The Role of Reflection

28. When helping clients learn to reflect, they should be encouraged to be in the present, acknowledge and accept feelings, and to notice _______________ without judgment.

A. Environmental triggers

B. Bodily responses

C. Inner experiencing

D. Emotional distress

Section 10: Skills to Improve Daily Life-Sleep and Rest

29. Sleep is essential for survivors because it rests the body, aids the processing of emotional experiences, and is critical in the formation of storage and consolidation of memories.

A. True

B. False

Physical Exercise

30. Strenuous physical exercise might not suit all survivors as increased heart rate, respiration, and sweating can mimic the arousal of sexual abuse.

A. True

B. False

Section 11: Managing Sensations, Feelings, and Grounding Skills

31. Hypo-arousal is associated with experiencing too much and being plagued by flashbacks, panic attacks, intrusive memories, thoughts and feelings, and often unexplained sensations or pain.

A. True

B. False

Loss of Control Over Feelings and Thoughts

32. It may be helpful to have clients identify triggers to trauma reactions by grading them on a scale of 1-4, with 1 being triggers they will always wish to avoid and 4 being those that are the least difficult to manage.

A. True

B. False

Grounding Techniques

33. The most effective way for survivors to ground themselves is to:

A. Focus on the traumatic reaction until it subsides

B. Connect to all five senses

C. Confront the unprocessed aspects of the trauma

D. None of the above

Section 12: Managing Flashbacks, Nightmares, Panic Attacks, and Dissociation-Internal Dialogue

34. To reduce the power of flashbacks, clients should be taught to use internal self-talk that is in the present tense such as, "He is coming to get me" rather than past tense, as they are able to have more  control over what is  going on in the present.

A. True

B. False

Panic Attacks

35. A good way to manage panic attacks is to mimic the sensations of the panic attack in a safe setting in order to show that the sensations are not life threatening and can be controlled.

A. True

B. False

Section 13: Managing Negative Thoughts and Beliefs-Common Biases in Thinking

36. Each of the following is an accurate statement about common biases in thinking that support negative beliefs EXCEPT:

A. Hypothesizng is the tendency to create a totally negative image on the basis of one, single minor deficiency

B. All or nothing thinking is the tendency to only see extremes rather than the full range of possibilities

C. Over-generalization is when we draw conclusions based on isolated events and apply these to a wide range of situations

D. Mental filtering occurs when positive aspects of a situation are filtered out leaving no choice but to dwell exclusively on negative aspects

Section 14: Managing Fragmented Memories-The Danger of Overprocessing

37. Memory recall is the best, and often times only validation of abuse, but clients should be made aware that they may not be able to restore full memory.

A. True

B. False

Pacing Memory Work

38. Before starting memory work, you need to assess your clients __________________ to ensure that they will be able to regulate these feelings.

A. Ability to manage their reactions

B. Current sense of safety and control

C. Level of functioning

D. Stage in the recovery process

Section 15: Managing Shame, Guilt, and Self Blame-The Function of Shame

39. Shame is a necessary survival trait as it alerts us to the fact that something is wrong about an experience or behavior, and acts as a prompt to seek help.

A. True

B. False

Helpful Therapeutic Strategies

40. To reduce shame and allow survivors to develop a more empathic view of themselves, they need to develop self-compassion which will enable the recognition that what happened to them was abuse.

A. True

B. False

Section 16: Managing Self-Harm

41. Addictive behaviors such as over-eating, gambling, or shopping excessively are considered passive self-harm activities since they don't cause direct self-injury.

A. True

B. False

Suicidal Ideation

42. Self-injury and self-harm can be used to manage suicidal thoughts and suicide attempts, although the motivation may be _________________ rather than death.

A. Communication of distress

B. To confront physical sensations

C. Cessation of pain

D. To calm and comfort

Setting and Managing Healthy Personal Boundaries-Collapsed or Rigid Boundaries

43. An example of a collapsed boundary is when a survivor avoids intimacy by being unable or unwilling to communicate, picking fights, working too much, or otherwise being unavailable.

A. True

B. False

Four Stages of Assertiveness

44. Which of the following is NOT one of the four stags of assertiveness that clients need to work through?

A. They have to decide precisely what it is they want or need

B. They have to decide on their own what is reasonable and fair

C. They generate a reasonable proposal which includes room for compromise

D. They consider and state the consequences if their proposal is not properly considered or is ignored

Section 18: Managing Relationships

45. Complex trauma and childhood sexual abuse can make it extremely hard to trust others or get close to them, which creates a paradox in which the survivor yearns for closeness and yet is compelled to avoid it.

A. True

B. False


46. The repeated betrayal in complex trauma leads to a basis lack of trust in self and others, so it is helpful for the clinician to review the client's level of trust throughout the course of the relationship as this is rarely static and will fluctuate.

A. True

B. False

Section 19: Managing Sexuality

47. The quality of a survivor's sexual relationship will be enhanced if he or she can communicate sexual _________________ without shame or fear of rejection.

A. Memories and experiences

B. Phobias and impulses

C. Beliefs and values

D. Fears and desires

Emotional Reactions

48. Sexual intimacy may trigger the same bodily sensations as during the abuse which may propel the survivors back to the abuse experience.

A. True

B. False


49. Ground rules that are necessary for a healthy sexual relationship include each of the following EXCEPT:

A. Saying "I love you" regularly

B. Taking time to think about and discuss sexual needs

C. Paying each other complements

D. Permitting each other to initiate or stop sex

Section 18: Managing Loss and Mourning-Grief

50. Grief that has been prolonged over many years and is usually accompanied by chronic clinical depression, persistent sadness, and a deep sense of hopelessness is known as daunting grief.

A. True

B. False

Reclaiming Losses

51. It may be helpful to have clients make a list of losses in order to identify those things that were missing in childhood and work toward reclaiming them.

A. True

B. False

Section 21: Restoring Reality and Trust in Self

52. In order for clients to restore trust in themselves rather than being influenced by others, and to rebuild their self-esteem and make positive choices, they need to develop their own:

A. Inner wisdom

B. Inner experiencing

C. Inner reliance

D. Inner assurance

Restoring Self-Reliance

53. Self-reliance, which is also referred to as self-sufficiency, occurs when survivors are confident that they can protect themselves from others.

A. True

B. False

Section 22: Relapse Prevention and Maintaining Self-Care

54. If there are any self-care strategies that clients have not been able to maintain, the clinician may suggest that they try some alternative ones or recommend that they adapt those that they have tried to better suit their needs.

A. True

B. False

Maintaining Relationships and Friendships

55. When clients are able to maintain relationships and friendships, they will find that they feel more connected to themselves, which will help them to maintain their self-care in making positive choices.

A. True

B. False

56. Clients need to realize that __________ are an opportunity to measure progress in how they are able to use all of the skills they have learned throughout their recovery.

A. Struggles

B. Disappointments

C. Obstacles

D. Setbacks

Section 23: Maintaining Post-Traumatic Growth

57. Survivors report seeing post-traumatic growth in six significant areas including personal strength, greater appreciation of life, getting closer to others, self-understanding, spiritual development, and:

A. Overall confidence

B. Greater control of emotions

C. Opening of new possibilities

D. Significant self-discovery

Part 5-Section 24 Practitioner Self-Care

58. Sometimes a practitioner can be so affected by the suffering and pain of others that compassion is eroded and replaced by feelings of powerlessness and helplessness.

A. True

B. False

Secondary Traumatic Stress

59. Secondary traumatic stress is characterized by symptoms which closely mirror those of:

A. Extreme anxiety


C. Depression

D. Somatic disorders

60. To ensure self-care on all dimensions, counselors should focus on seeking contentment in the areas of work, body, mind, emotion, creativity, and spirituality.

A. True

B. False

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