Understanding Complex PTSD
There is a lot of confusion around the idea of trauma and trauma treatment.
Trauma can be a single event, but it can also be ongoing (or chronic).
Often we think of post-traumatic stress disorder (PTSD) in relation to the experiences of soldiers in combat or people who have been through natural disasters.
But trauma can also be caused by repeated and chronic experiences of neglect, abuse, domestic violence or abandonment by a parent or caregiver.
PTSD is a fear-based disorder which will produce symptoms such as hypervigilence and intensely vivid reliving of traumatic experiences. People with Complex PTSD will experience these symptoms, but also disturbances in self-organisation (identity or sense of self). These disturbances are reflected in ongoing problems to do with emotion regulation, self-concept and relational difficulties.”(Cloitre et al 2014)
Complex trauma caused by childhood experiences is particularly damaging, due to the special vulnerability of children - and it has substantial impacts, on both mental and physical health into adulthood.
Complex trauma is usually triggered by emotionally abusive relationships in childhood where the child is unable to integrate damaging and overwhelming experiences. The symptoms of complex PTSD are caused by ongoing or repeated trauma where the victim has little or no control and no real or perceived hope of escape (for example where a child is threatened or abused by an adult).
The perception of extreme and overwhelming threat in this kind of trauma activates the physiological `survival' responses of 'fight-flight-freeze'. These survival mechanisms are innate and biologically programmed. They 'cannot be helped’. The responses that are part of Complex Trauma are not able to be thought about or reflected upon and remain unintegrated because they are too overwhelming for the developing child.
Recovery from trauma is not about `will power' or deciding to `move on'.
The trauma that results in Complex PTSD usually occurs at vulnerable times in the victim's life – including early childhood or adolescence – creating long-term developmental challenges.
Complex PTSD causes issues with emotion regulation, problems with relationships, anxiety, depression, low self-esteem and deeper deficits to do with identity or sense of self.
“Childhood (complex) trauma can seriously affect a person's ability to function, their sense of themselves, and their capacity to regulate arousal, emotions and behaviour. It impairs self-conception and cohesion, one's sense of meaning, and the capacity to relate to others.”
Unlike PTSD, complex trauma disrupts a person's identity, severely adversely affecting a person's relationship to themselves, others and the world.
Often people with Complex PTSD don’t know that they have it.
They think that they “just are” and that the life-issues and problematic patterns which keep recurring are a result of circumstances or their own failures.
Some Symptoms of Complex PTSD
Difficulties expressing emotion – High emotional sensitivity and a reduced ability to respond to situations in a manner that is socially tolerable.
Negative self belief – A perception fostered by the opinions of others and negative experiences, leading to feelings of worthlessness and shame.
Problems maintaining healthy relationships – Difficulty feeling close to another person and a general feeling of disconnection, distance or being cut off from other people.
A diagnosis of Complex PTSD can take a long time as symptoms commonly overlap with other mental illnesses such as depression, PTSD and borderline personality disorder.
Symptoms that overlap with other mental illnesses include:
Avoiding thinking and talking about trauma-related topics because the feelings are overwhelming
Use of alcohol or other substances as a way to avoid or numb feelings and thoughts related to the trauma
Engaging in self-mutilation and other forms of self-harm
People are sometimes unjustly blamed for the symptoms they experience as a result of victimisation
Alterations in attention and consciousness, known as dissociating.
Treatment for Complex PTSD
Distress tolerance strategies and self-soothing techniques are important skills for survivors of trauma. It's also important for survivors to be supported in an environment where they can feel safe.
Psychotherapy with a trauma-focused psychotherapist can help sufferers understand and develop awareness around their trauma in a safe environment. Generally trauma therapy takes anywhere from 6 months to 5 years depending on the severity of the trauma - Complex Trauma is not a quick fix.
Some common trauma treatments such as EMDR (Eye Movement Desensitization and Reprocessing) do not work for Complex PTSD as they are designed for discrete episodes of trauma (i.e. a single incident such as a car accident, or an assault).
Psychotherapy for Complex Trauma
Successful treatment for Complex Trauma will address the developmental aspects of the trauma. These developmental aspects often incorporate “self” or identity problems depending on the stage at which the trauma(s) occurred.
“Sense of self” or identity problems are extremely distressing for the person with Complex Trauma and can often be challenging to resolve in therapy.
These underlying problems can manifest in complications such as
difficulties managing mood and emotion
inability to maintain relationships
unfocussed life direction, values and aims
ongoing feelings of worthlessness and shame
Without treating the underlying trauma, symptoms such as anxiety or depression will not be resolved.
Psychotherapy for complex trauma focusses on gently uncovering and developing self awareness around the trauma in a safe and controlled way. Trauma therapy also treats Complex PTSD by providing a reparative experience of relationship to help resolve the relational aspects of the trauma.
Because Complex PTSD is often the result of negative experiences in early attachment relationships, therapy aims to create a positive, empathetic and nurturing therapeutic relationship.
How Psychotherapy Can Help you Recover
The negative experience of self created through the original trauma in Complex PTSD often includes very intense feelings of shame which can be triggered through relationships and social interactions.
These early shame experiences often resulted in disorganisation (or a sense of psychic annihilation or falling apart) because the young child was not able to resolve or incorporate these intense experiences on their own and they were not soothed or comforted by caregivers.
Feelings of worthlessness and chronic shame are often experienced unconsciously by adults with Complex PTSD - they don’t know that that is what they are experiencing. These feelings will be “running in the background” and form a dominant part of their experience of self. This causes a flow on of associated problems as listed above.
Psychotherapy can help by providing a reparative experience of relationship for people with Complex PTSD.
An empathetic therapeutic relationship will help you learn to trust yourself and others again.
Trauma therapy will allow you to become close to someone without being shamed AND to gain an awareness of how chronic shame is impacting your life and your relationships.
As you experience shame within the safety of the therapeutic relationship without being “lost in” its isolating and debilitating effects, you will gain familiarity with the bodily sensations and states accompanying shame.
Putting a name to our feelings - including and most importantly - shame, allows us to maintain awareness and stay “with” ourselves, so that we do not become disorganised in the face of this intensely overwhelming emotion.
Although chronic shame is not something which can be completely erased, psychotherapy helps us learn to live with it and to lead joyful and connected lives, alongside diminishing experiences of shame.
Psychotherapy can help you rediscover yourself and be the person you were always meant to be.
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More from the recovery room
Self-Care for Complex PTSD
A helpful part of recovery is maintaining self-care. This involves very simple, day-to-day acts that give a person control over their environment. When in an overwhelming emotional state, a self-care strategy can help ground you, bring you out of the state and help you regain control over the difficult emotions.
'Self-compassion has helped me a lot. We were far from validated as children, so now we have to get in touch with those fragmented parts, the parts we had to detach to cope. We have to comfort and nurture and strengthen on the inside so we're not so impacted by the world.'
Marylène Cloitre, Donn W. Garvert, Brandon Weiss, Eve B. Carlson, and Richard A. Bryant (2014) Distinguishing PTSD, Complex PTSD, and Borderline Personality Disorder: A latent class analysis, European Journal of Psychotraumatology 2014; 5: 10.3402