PART III

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.

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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.