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Complex post-traumatic stress disorder (CPTSD) is a complicated mental health disorder that is incredibly challenging to diagnose and treat. Understanding some of the best practices for working with complex trauma can help therapists determine how to help a complex PTSD client in their practices. Understanding the Nature and Impact of Complex Trauma on Mental Health Complex trauma is a unique phenomenon that takes much longer to process than more well-known types of trauma. The term specifically refers to an individual's exposure to repeated interpersonal traumatic stressors — deliberate instances of abuse that continue over a long period of time. Complex trauma usually occurs during the survivor's childhood, though it can also affect adolescents and adults.  In general, survivors of interpersonal trauma tend to exhibit more severe stress responses than people who experience impersonal traumatic events like natural disasters or accidents.  Causes of complex trauma can include: Abuse: Emotional and physical abuse in familial relationships are some of the most common causes of complex trauma. Caretakers outside the immediate family can compound this abuse by failing to intervene — which often destroys an individual's ability to trust other people. Scarcity: Homelessness, extreme poverty and starvation due to financial instability, displacement or community violence often cause lasting trauma. Intergenerational trauma: People who experienced trauma in their own childhoods often pass that trauma on to their children through emotional or physical abuse, creating a cycle of violence within the family.  Violence: Prolonged exposure to war, death and other violence can cause individuals to become hypervigilant and skeptical of other people. Systemic triggers: The effects of systemic problems like institutionalized racism, sexism, homophobia and religious discrimination can cause individuals to develop heightened stress responses as a mode of self-defense.  CPTSD and Its Relation to Complex Trauma Complex PTSD (CPTSD) is a form of post-traumatic stress disorder (PTSD) that forms as a result of prolonged exposure to complex trauma. While psychologists have submitted proposals to include CPTSD as an official diagnosis in the DSM-V, it is still under evaluation. However, the World Health Organization (WHO) includes the condition in the International Classification of Diseases (ICD-11).  It's important to note that while CPTSD shares many similarities with traditional PTSD, there are some key distinctions between the two: PTSD: Following a traumatic event, the survivor reexperiences their trauma, avoids anything that triggers their memory of the event and believes they are constantly under threat (hypervigilance). CPTSD: According to the ICD-11, complex PTSD includes all the diagnostic criteria for PTSD as well as an assortment of other symptoms that resemble other mental health disorders. CPTSD also must stem from repeated interpersonal trauma rather than short-term impersonal incidents.  Recognizing Signs and Symptoms of CPTSD in Clients Although the ICD-11 lays out clear criteria for identifying cases of complex PTSD, the condition often resembles other mental illnesses. Careful evaluation is critical for arriving at the correct diagnosis. Identifying Complex PTSD Symptoms CPTSD shares 17 symptoms with traditional PTSD, which can be grouped into the following clusters: Intrusive thoughts: Survivors often experience intense flashbacks where they relive their past trauma as though it is happening in the present. Nightmares are also common. Avoidance: Often, patients with CPTSD will go out of their way to avoid people, places and behaviors that remind them of their trauma. Although avoidance may seem to protect the individual's mental well-being, it often interferes with their ability to function. Altered thinking and moods: Many survivors also struggle with thoughts of suicide or self-harm. Somatization: Research has shown that CPTSD can contribute to a survivor's existing medical conditions, such as autoimmune conditions and chronic pain. While these symptoms may reflect physical abuse the patient experienced, they can affect any body system. Other symptoms that are unique to CPTSD include: Distorted view of the abuser: The client may adopt some parts of their abuser's belief systems or develop an unhealthy preoccupation with them. In some cases, the client may also become preoccupied with revenge.  Distorted sense of self: The client internalizes the abuse they experienced, resulting in a predominantly negative self-image and intense feelings of guilt and shame. Difficulties maintaining personal relationships: Many people who suffer complex trauma lose the ability to place their trust in others, developing a warped view of the world in which people are inherently unreliable. Broken systems of meaning: Complex trauma survivors often lose their connection to core values and belief systems, creating a sense of hopelessness and despair.  Difficulty regulating emotions: People with CPTSD may overreact or underreact to emotional stimuli, which can make it more difficult for them to successfully interact with other people. The Four Defense Mechanisms of CPTSD Survivors of complex trauma also typically develop an over-reliance on one or two of the Four F defense responses: Fight: The survivor responds to painful emotions with aggression, believing that exerting power and control over others will bring them safety. Common manifestations include explosive tempers and controlling behaviors.  Flight: The survivor attempts to avoid their inner pain and interactions with others by being constantly busy. This type can manifest as workaholism, perfectionism and adrenaline addictions. In extreme cases, the survivor can develop severe anxiety and/or panic disorders. Freeze: The survivor develops a belief that others are inherently dangerous, leading them to spend unhealthy amounts of time in solitude where they can feel safe. It frequently manifests in dissociative behaviors and social isolation. This type also frequently seeks out forms of escapism, such as video games or sleeping, to avoid interaction. Fawn: The survivor adopts a helpful, compliant persona to protect themselves from the pain of rejection. These individuals are typically people pleasers who go out of their way to avoid conflict. Codependency and an inability to express one's needs are common expressions of the Fawn type. Although people who do not suffer from CPTSD can use all of these defense mechanisms in healthy ways, survivors often form a tendency to use one or two exclusively.  The Critical Role of Therapists in Diagnosis CPTSD is a challenging diagnosis because it shares so many symptoms with other mental illnesses, such as PTSD and borderline personality disorder (BPD). Trained mental health professionals have the skill set necessary to identify patterns in a client's profile and determine whether they fit the diagnostic criteria for CPTSD or if another diagnosis would be more appropriate.  Therapeutic Approaches to Complex Trauma: A Comprehensive Guide Because patients suffer the burden of chronic trauma for years before seeking help, treatment for CPTSD typically takes much longer than for less complex conditions. Best practices for complex trauma treatment begin with a multiphase approach: Initial assessment: The therapist builds rapport with the client and collects data about their symptoms. Once they are sure the client is dealing with CPTSD, they can create a treatment plan and explain what to expect. Early stage: After the initial intake session, the therapist must establish the client's safety and help them regain a sense of control over their body. This step is foundational for the entire recovery journey, as it teaches the client healthy coping strategies for the later stages. Middle stage: The client begins talking about their traumatic experiences, which helps them make sense of what happened. The therapist plays an active role by reinforcing the coping skills learned in the early stage, which helps prevent the client from falling back on one of the four Fs so they can feel and grieve their pain in a healthy way. Late stage: Finally, the therapist helps the client build a healthy sense of self and teaches them strategies for connecting with others.  Note that these stages will often overlap due to the nature of complex trauma. At every phase of treatment, therapists should communicate with clients to ensure their physical safety before they work on processing their trauma. Established Therapeutic Approaches Psychotherapy, or talk therapy, is the basic modality used to treat complex PTSD. The therapy may take place one-on-one or in a group, depending on the therapist's approach and the client's level of comfort. Psychotherapy techniques commonly used as part of a complex PTSD treatment plan include: Cognitive behavioral therapy (CBT): The therapist and client work together to understand the root cause of the trauma so they can come up with effective coping strategies. Prolonged exposure (PE): Gradually talking through and directly processing the trauma in a safe setting can help reduce symptoms and give clients a greater sense of control. Eye movement desensitization and reprocessing (EMDR): This approach uses eye movement patterns as a way to divert some of the client's attention away from their trauma. Shifting the focus in this way helps the client discuss what happened without becoming re-traumatized. Medications: Psychiatrists may prescribe antidepressants to supplement other treatments. Zoloft (sertraline) and Paxil (paroxetine HCl) are the only FDA-approved medications for PTSD treatment, but Prozac (fluoxetine) can also be prescribed off-label. Emerging Therapies and Techniques Trauma-informed care (TIC) is a relatively new approach that shifts the focus of complex PTSD treatments from the client's condition to their experiences — asking, "What happened to you?" rather than, "What's wrong with you?" This approach helps therapists avoid re-traumatizing their clients during treatment, which is a serious risk.  Other emerging treatments include using consciousness-altering substances like ketamine and psilocybin to safely guide clients through processing their trauma. Although these therapies are still in their early stages, they are seeing promising growth in the United States. Building Resilience in Clients With Complex Trauma and CPTSD Resilience is the ability to adapt well to traumatic and stressful situations. Studies have shown that building resilience can help reduce the symptoms of CPTSD — in general, the more agency a survivor can take over their life, the more manageable their trauma will become.  Some evidence-based techniques for building resilience include: Accepting the reality of one's traumatic experiences. Building trust in others through participation in support groups. Repairing the relationship between the surviving self and the thriving self. Developing healthy coping mechanisms to get through feelings of trauma. Taking good physical care of oneself even during periods of stress. Setting realistic goals for the future. Avoiding alcohol and other substances. Practicing mindfulness through journaling, prayer or meditation. Seeking help in dangerous situations. Of course, therapists should take great care to avoid re-traumatizing their clients during this process. Reinforcing safety and revisiting healthy coping skills is essential at each stage of treatment. How to Help Clients With Complex Trauma in Therapy: Strategies and Techniques Because people with CPTSD have difficulties forming and maintaining close personal relationships, it can be challenging for therapists to fully engage their clients during treatment.  Building Trust and Support Complex trauma shatters a survivor's ability to trust others, which can make providing effective treatment challenging for therapists. Before any real work can begin, the client must feel safe with their therapist — and if they have had previous negative experiences with therapists, it can be even harder to gain their trust.  Beginning the treatment plan by establishing that your office is a safe space is critical. Your clients should know that everything they tell you is private and that you will not judge them for anything they share with you. It may also help to give your client space to mistrust you. Their traumatic experiences have only shown them that distrust is the safest way to approach other people, after all. Emphasize that you only need them to work with you — this can help you determine the cause of their broken trust so you can help them understand it.  Addressing Common Misconceptions About Complex Trauma and CPTSD Although our society has come a long way in understanding mental health issues, many misconceptions persist surrounding trauma and its effects.  Some of the most common myths about complex trauma include: Only life-threatening events cause trauma: Physical danger is a common cause of trauma, but it is not the only one. Years of emotional abuse at the hands of caretakers and significant others can leave lasting damage that can interfere with the survivor's ability to pursue a fulfilling life. Trauma will ruin your life: While it's a common belief that people who have experienced complex trauma can never recover, there are many evidence-based treatments therapists can use to assist their clients in moving beyond the trauma. All complex trauma survivors get CPTSD: Although complex trauma is distressing for all survivors, only a small proportion will develop full-blown CPTSD. Regardless, therapists should take care to treat all clients who have experienced trauma with the proper respect. The Role of Therapists in Disseminating Correct Information Therapists play a vital role in combating misinformation about CPTSD, especially in today's age of digital misinformation. People who have a skewed view of CPTSD are more likely to treat people suffering from the disorder with respect, which can further traumatize them. And some clients may come to therapy with a fundamental misunderstanding of their condition, which could lead them to resist treatment.  Final Thoughts and Suggestions for Helping Clients With CPTSD As more mental health practitioners become aware of CPTSD, we're sure to see more advances in treatment techniques. Keeping up to date with evolving treatments and techniques can help you ensure your practice delivers the best possible care.  Finally, remember that CPTSD treatment can take a long time. Some survivors may even need treatment for the rest of their lives — both continuous and episodic. Paying attention to your client's individual needs can help inform treatment length.  How ICANotes Can Help Therapists Support Patients With CPTSD ICANotes is a robust electronic charting solution designed specifically for mental health care. Our software helps practitioners save time on note-writing so they can focus on delivering the best care to their clients. Contact us today to request a free trial or to schedule a live demonstration. 

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