Addressing the Unique Features of CPTSD

Any treatment for cPTSD must take these features into account. It needs to engage with the person holistically, and allow discussion of traumatic material without triggering the suppressive/dissociative reaction. Luckily there are techniques in psychology capable of doing exactly that. But before we get into those, we need a brief explanation of two important concepts: process and transference.

Process refers to any spontaneously arising reactions to therapy as it unfolds. Just about anything can be process – glottal stops, elisions, hesitations, blushing, etc. – as long as it happens in response to something occurring in therapy. A good example might be someone shifting in their seat when the topic of dating arises. A therapeutic intervention based on process might be as simple as the question, “Why do you shift in your seat when you talk about dating?” Or, if the therapist has more context, it might include an interpretation: “You shifting in your seat tells me the date last night didn’t go well.”

Transference refers to how a patient experiences their therapist. Often a patient will experience their therapist as indifferent, or sadistic, or maternal, or seductive, or any number of different things, based more on previous relationships than on anything that the therapist has actually done. An example would be a patient who assumes their therapist is angry with them for rescheduling an appointment. A therapeutic intervention based on transference could take the form of simply asking, “Are you expecting me to be angry with you for rescheduling?” Or, if the therapist has more context, could include an interpretation: “Your mother used to punish you if you allowed anything to come before her, and I think you expect me to do the same.”

Techniques based in process and transference are surprisingly effective with cPTSD. For one thing, there is a substantial qualitative difference between someone asking you to recite your trauma and someone asking you why you are doing something. The former is prescriptive while the latter invites self reflection and understanding. More importantly, though, is how these techniques take the focus off what happened and place it on what is happening now. How is trauma influencing this moment, this choice, this feeling in this instant? This engages the whole person, as they are now, and brings conscious attention to the interplay of trauma and personality. Best of all, I’ve found that approaching traumatic material in this way, through the present moment, does not usually trigger the suppressive/dissociative reaction. It invites someone to be an observer and interpreter instead of a reciter.

PART IV

The Technique in Practice

Something terrible happened to Maria that she knows about but can’t remember. It happened when she was a girl. It was sexual in nature. Beyond that she cannot say.

She has intense reactions she doesn’t understand. One happened during a standard college orientation presentation about sexual assault. Another happened with her girlfriend. Both of these incidents rendered her nonfunctional for weeks. These episodes are accompanied by images. She can’t describe the images because when she tries she immediately dissociates and she feels like she’s floating above herself.

She had given up on therapy. She only agreed to try again because her girlfriend was desperate for her to get help, and someone she trusted recommended me. When she first started she spoke only in monosyllables. She never made eye contact, but never stopped watching me. She sat poised ready to flee, literally.

This excerpt comes from one of these early sessions, when she was just beginning to trust me. It was selected because it demonstrates how a process-based approach can lead to substantive therapeutic work. Name and some details altered to insure anonymity

Therapist: I notice you nod at me when I’m talking.

Maria: (nods)

Therapist: I feel like maybe you do that to reassure me I’m doing a good job.

Maria: (thinking) Maybe.

Therapist: Maybe?

Maria: (nods)

(long silence)

Maria: Some of it is because it fits, what you’re saying. But some of it is that. Reassuring you.

Therapist: Why might it be important to reassure me I’m doing a good job?

Maria: So you get what you want. And I can keep being me. Like underneath.

Therapist: You let me think I’m effective so that I won’t bother you anymore.

Maria: (nods)

Therapist: Where else do you do that?

Maria: (eyes going wide)

Therapist: What?

Maria: Everywhere. I do it everywhere. Meeting with my advisor. Waiting for the train.

Therapist: You seem shocked.

Maria: I didn’t realize I went through life like that.

This was something of a breakthrough. In subsequent conversations Maria explained how this moment really brought home how frightened and cornered she felt whenever she interacted with straight men. It was a feeling she was aware of previously, but only dimly, and took as a normal part of everyday experience. Her broadened understanding rendered these interactions easier. Life got a little better.

CBT or EMDR would have been useless with Maria. She simply could not explicitly confront her trauma. Granted, Maria’s dissociation was especially pronounced, but her case illustrates the point. CPTSD requires techniques that engage with the personality, and avoid the suppressive/dissociative response. Exposure-based therapies like CBT and EMDR might scratch the surface, but they don’t take cPTSD’s nature into account. CPTSD is different, and it needs to be treated differently.

Brian Henley is a clinical psychologist in Los Angeles, California. For more information, visit his website at treatingcomplexptsd.com, or read his recent article at https://doi.org/10.1080/02668734.2023.2231059

Guest Post Disclaimer: Any and all information shared in this guest blog post is intended for educational and informational purposes only. Nothing in this blog post, nor any content on CPTSDfoundation.org, is a supplement for or supersedes the relationship and direction of your medical or mental health providers. Thoughts, ideas, or opinions expressed by the writer of this guest blog post do not necessarily reflect those of CPTSD Foundation. For more information, see our Privacy Policy and Full Disclaimer.

Brian Henley

Brian Henley is a licensed clinical psychologist based in Los Angeles. He specializes in the treatment of traumatic stress. You can find out more about his practice at his website, https://treatingcomplexptsd.com/, or read more about his theory and methods in his recent article, Psychodynamic Techniques Elicit Emotional Engagement in Complex Post-Traumatic Stress Disorder, available here: https://www.tandfonline.com/doi/full/10.1080/02668734.2023.2231059.

The year was 2013, and the American Psychiatric Association was putting their final touches on their latest edition of the Diagnostic and Statistical Manual of Mental Disorders; their ponderous compendium of classifications and criteria that has become the standard reference book for mental health practitioners throughout the United States. It’s a very influential book. Each edition sends expanding ripples of consequences throughout the field for years and years. Decades and centuries, arguably. Consider for a moment the effect it had when homosexuality, for one example, was de-pathologized in a previous edition.

In anticipation of this event, there was a major push on to convince the APA to recognize complex PTSD, in some name (DESNOS, dissociative subtype), as a separate diagnosis. If you scan the literature, there is a dramatic increase, a huge swell, in the number of research articles supporting cPTSD right around 2013, as researchers across the world made their case for its inclusion.

Sadly it did not make the cut. The criteria for PTSD in the new DSM-V were amended to reflect some incontrovertible findings, but the APA in its wisdom ruled that cPTSD, as a thing, was not sufficiently distinct to merit its own separate entry.

And yet the diagnosis thrives. In the absence of formal classification (in the United States), it has grown in the public’s awareness and entered the common lexicon, and is in frequent use amongst researchers and clinicians. The reason for this is that cPTSD exists, and it is a useful distinction to make, especially clinically. Saying that someone suffers from cPTSD, if it is understood what that means, immediately provides a wealth of information that might otherwise take a great deal of time to ascertain in a treatment setting. Furthermore, and crucially, knowing that cPTSD is present guides treatment choices, because cPTSD needs to be treated differently than uncomplicated PTSD. I can’t say this enough. I wish I could write it in the sky: cPTSD needs to be treated differently than uncomplicated PTSD.

PART II

Unique Features

The most frequently recommended treatments for cPTSD are Cognitive Behavioral Therapy (CBT) and Eye Movement Desensitization and Reprocessing (EMDR). Look on any website talking about cPTSD, click on their “resources” tab, and there they are: CBT and EMDR.

The problem is that these two don’t work very well with cPTSD. They are based on the exposure model, which was developed before anyone had ever thought of cPTSD. In the exposure model, treatment consists of exposing the patient to the traumatic incident over and over, usually in the form of reciting a trauma script or prompts from the therapist to imagine this or that aspect of the trauma. The feelings this inspires (fear, terror, helplessness) are then processed until they subside.

CPTSD, however, presents with two unique features that confound the exposure model. The first of these is that whereas in uncomplicated PTSD, the trauma represents an atypical event (i.e. someone is going about their lives when something terrible and abnormal occurs), in cPTSD the trauma is formative, in that it is a circumstance or condition under which the person learns and grows (i.e. being raised in an abusive home). In that situation, trauma is adapted to, built upon, and incorporated into the self. In cPTSD, trauma pervades the personality. This makes it much harder to confront through exposure, because the problem isn’t that someone is now triggered by discreet stimuli like dark alleys or specific memories. The problem is that someone is engaging with the entire world, and relating to themselves, from a holistically traumatized standpoint. Addressing that requires a more comprehensive engagement with the person than repeating painful recollections.

The second unique feature of cPTSD that messes with the exposure model is what I call the suppressive/dissociative reaction. I call it that because it isn’t just dissociation. Dissociation is a largely involuntary reaction that can range from simple “spacing out” to severe and exotic phenomena such as depersonalization (when someone feels as if they are outside of their body). Dissociation certainly happens in cPTSD. However, in my experience people with cPTSD suppress as much or more than they dissociate. Suppression is a mostly deliberate, conscious effort to stifle feelings, and operate as if they aren’t there. People with cPTSD suppress all the time, which makes sense: if your trauma was prolonged, you were going to have to pretend that everything was fine a lot. Because both of these processes are present in cPTSD, and serve the same function (managing intolerable emotions), I combine them into a single term: the suppressive/dissociative reaction. The suppressive/dissociative reaction impedes exposure-based therapies by rendering emotions inaccessible. If all someone does when you expose them to a trauma script is shut down or dissociate, the emotions you’re hoping to process won’t show up, and the therapy won’t work.

Last part of this section: why, if they don’t work very well, are CBT and EMDR recommended for cPTSD so much? Well, I have a few theories. One, they were being used to treat PTSD, so when cPTSD came along people naturally thought “Sounds similar, these oughta work on that, too.” Two, insurance companies love CBT and EMDR because they can be manualized, so they get advertised quite a bit. Three, most websites talking about cPTSD are getting the word out, not doing research, so they copy/paste their recommendations from each other. Website content that is auto-filled by AI will also list CBT and EMDR. Four, they do kinda work – most studies done with CBT or EMDR on cPTSD show some symptom reduction; just not as much as they have on PTSD. And five, it might reflect the ongoing push to medicalize psychology.

Guest Post Disclaimer: Any and all information shared in this guest blog post is intended for educational and informational purposes only. Nothing in this blog post, nor any content on CPTSDfoundation.org, is a supplement for or supersedes the relationship and direction of your medical or mental health providers. Thoughts, ideas, or opinions expressed by the writer of this guest blog post do not necessarily reflect those of CPTSD Foundation. For more information, see our Privacy Policy and Full Disclaimer.

Brian Henley

Brian Henley is a licensed clinical psychologist based in Los Angeles. He specializes in the treatment of traumatic stress. You can find out more about his practice at his website, https://treatingcomplexptsd.com/, or read more about his theory and methods in his recent article, Psychodynamic Techniques Elicit Emotional Engagement in Complex Post-Traumatic Stress Disorder, available here: https://www.tandfonline.com/doi/full/10.1080/02668734.2023.2231059.