PART I
Treat it Differently
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.
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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.
Brian Henley, I can’t thank you enough for this article. There are so many things that resonate. Childhood abuse and neglect by a raging mother who would burst into my bedroom as I read, pull me out of bed and come at me with a knife saying she would kill me for reading. How can an 8-9 year old’s nervous system handle that type of abuse? It can’t. I learn to be hypervigilant. By 11 had developed cystic acne which I now think was body’s respond to constant trauma. Began dating at 15 looking for love. Found it and he began beating me at 16. Stayed, married him and talked myself out of leaving until severe trauma at age 44. Was free but still searching for elusive love, choosing men who latched onto my people pleasing nature. At 58, met and married someone who doesn’t physically abuse me but has denied my major needs for 14 years. His life became my life. I was blind to my patterns until recently. How could that be? Am fairly intelligent. But the need to be loved seemed to supersede all intelligent reasoning in my brain. And at 72, still searching for a therapist who can help. Have spoken to half dozen over the years, but they never really listened; feels like lip service. With this website (and hopefully more insightful articles by you) I will find solace. My heart is so worn out from all the years of trying to be validated and loved. When I was around 4-5, my mother would pack a bag of my clothes, pick up the phone and call ‘the home’ to send me away. I’d plead, ‘please, please Mommy, don’t send me away. Let me stay’. That inner child has never left me. You don’t know me but somehow you heard me. Thank you Brian.
Thank you for these excellent insights. They resonate deeply. I look forward to reading more. I’ve already ditched CBT as a therapy and am doing inner child work with my current therapist. She has also suggested emdr. Your article raises some very interesting talking points.
Please don’t give up! A good therapist can be hard to find, but it’s never too late to heal. Your story is heartbreaking.
Yes, thank you for this piece! I suppress my trauma/cPTSD by moving, doing & giving. My frenetic pace holds the demons of my cPTSD away. I don’t feel or remember anything when I’m not paying attention to myself. Thank you again! Erin (Canada)
So, what is the best treatment option for CPTSD, in your opinion?
As someone diagnosed with CPTSD, it was frustrating to read what doesn’t work, without offering alternatives.
I’m sorry! It is detailed in parts 3 and 4 of this article, which I’m told are going to be published in a few days.
This makes absolute sense to me in my journey thus far in therapy. Here in New Zealand, those of us who have suffered childhood sexual abuse are able to freely access therapy when symptoms arise at whatever age or stage in life. At different times through this process those involved as a client are obliged to recount the abuse as fully as possible, to show that they are still entitled to the help of a therapist. As a recipient, and a truly grateful one, of this help, I have found the remembering and recounting to be as harmful as the actual abuse, especially so as I’m beginning to feel the feelings I learned to suppress and dissociate from during my childhood and adolescence. Understanding what is happening makes it easier to deal with. So thank you for such articles as this one.
I now comprehend why life is so hard for me. It is impossible to “just let it go,” or “move on,” because it, the trauma, is mixed into the concrete of my foundation.