Sequenced Relationship-Based Psychotherapy for Complex Posttraumatic Stress Disorder: Commentary on the Application of the Model to the Hybrid Case of "Chloe"
Authors: Courtois Christine , Ford Julian 
Published: June 2022

In this commentary, as authors of the Sequenced, Relationship Based Treatment Model—developed for complex posttraumatic stress disorders—we respond to its detailed application to the hybrid case of "Chloe," reported by Chloe’s therapist, Dr. Phoebe Shepherd (2022). Shepherd reviewed different treatment approaches before choosing our model, due to its sequenced and hierarchical approach, comprehensive description in the literature of its application in a primary text by the model’s authors, and flexibility of utility and choice of technique. The latter are based on the judgment and training of the therapist and on the client’s unique situation and needs, as well as preference.

As in the model, Chloe’s treatment takes place in a sequenced and chronological form over a two-year period while Shepherd worked at a psychological training clinic. Shepherd  received ongoing expert supervision while conducting this treatment. She not only described the model and the techniques she selected, but also how they were applied and adapted to the client’s status over the course of the treatment. She also described her own process over the course of the treatment, as she addressed its challenges and its starts and stops as she experienced the client. Appropriately, Shepherd began the treatment with assessment, which was repeated several times over its course to document progress and change. As discussed in descriptions of the model, although it is linear on paper, the actual progression of treatment is instead flexible and recursive, returning as needed to the tasks of the early phase of treatment (i.e., emotional regulation skills and personal stabilization).

In this commentary, we support Shepherd’s primary interventions and their rationale while also offering cautions and re-direction for some of them. All told, the case description offers endorsement of the sequenced, relationship-based treatment model, and how it guides the therapist in working with the multi-problem and challenging population of Complex PTSD as represented by the hybrid case of Chloe. Chloe’s history encompassed adverse and potentially traumatizing experiences in childhood, including: father’s alcoholism; mother’s emotional instability and unavailability and ongoing threats of suicide; parental divorce at age 10 with custody awarded to Chloe’s mother; paternal abandonment post-divorce; and suggestions by grandparents that Chloe was responsible for her mother’s problems and their lack of appropriate intervention on her behalf. These adverse experiences resulted in Chloe’s mistrust of and detachment from others and emotional fragility, including a tendency towards isolation and depression. Her major trauma occurred a year prior to the treatment when she interrupted her mother’s attempt to shoot herself in the head to commit suicide, the effects of which ultimately led Chloe to seek counseling. The treatment was directed not only at the effects and symptoms of the recent trauma (using trauma-focused, evidence-based techniques), but also more broadly at Chloe’s prior traumatic exposures and her developmental and skills deficits. The case description also demonstrates the impact of the therapeutic relationship as the context and as a healing factor in the treatment.