As we face the worrying increase of environmental events, pandemics, and wars across the globe, the topic of trauma is extremely relevant across various contexts.
It can potentially result in post-traumatic stress disorder (PTSD) or complex post-traumatic stress disorder (CPTSD).
In a therapeutic context, we’re seeing more and more people in our practices who have been exposed to the deep wounding and trauma of these events.
The increasing occurrence of CPTSD is particularly alarming, and as therapists, we need to be equipped with an understanding of this condition and how to support our clients as they navigate their trauma experiences.
In this article, you’ll learn more about complex PTSD: how to spot it, differentiate it from other similar conditions, and support your clients, as well as useful resources you may want to use or share with your clients.
Before you continue, we thought you might like to download our three Resilience Exercises for free. These engaging, science-based exercises will help you effectively deal with difficult circumstances and give you the tools to improve the resilience of your clients, students, or employees.
Complex post-traumatic stress disorder (CPTSD) is a mental health condition that arises from exposure to prolonged, repeated trauma, often occurring over an extended period (Resick et al., 2012).
This trauma typically involves interpersonal abuse, neglect, exploitation, or violence, which can occur in various contexts such as child abuse, domestic violence, human trafficking, captivity, or war experiences.
CPTSD symptoms often permeate multiple aspects of an individual’s life, making it difficult to engage fully in activities and responsibilities (Balayan et al., 2014). This can profoundly disrupt daily functioning, leading to challenges in interpersonal relationships, academic performance, maintaining employment, and overall quality of life.
You can learn more about CPTSD in Forrest Hanson’s YouTube video, Complex PTSD in 5 Minutes.
Complex PTSD in 5 minutes - Forrest Hanson
Causes & Symptoms of Complex PTSD
CPTSD is deeply connected to prolonged or repeated traumatic experiences, particularly in situations where escape or avoidance is not possible (Franco, 2021). Chronic childhood trauma and interpersonal trauma are both examples of potential causes (Karatzias & Levendosky, 2019).
Systemic trauma, involving societal injustices or discrimination, may also cause CPTSD because it erodes people’s sense of safety and belonging (Gutiérrez, 2022). Additionally, war trauma, including combat exposure and captivity, can trigger CPTSD (Letica-Crepulja et al., 2020).
Symptoms of CPTSD encompass a wide array of challenges affecting emotional, cognitive, and interpersonal functioning (Cyr et al., 2022). These may include emotional dysregulation, intrusive memories, avoidance behaviors, negative self-perception, impaired relationships, hypervigilance, and a distorted worldview.
Triggers evoke intense emotional or physiological reactions linked to past trauma, which may perpetuate distressing symptoms (Franco, 2021). CPTSD triggers stemming from past traumatic experiences can evoke intense emotional reactions and interpersonal challenges in relationships. This can impact trust, communication, and emotional intimacy.
It’s essential to recognize that the presentation of CPTSD can vary widely, and not everyone who experiences trauma will develop these symptoms. A person-centered approach is therefore vital for the accurate diagnosis and effective treatment of CPTSD.
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Risk & Protective Factors of CPTSD
Risk and protective factors are pivotal in shaping the experience of those exposed to trauma (Leiva-Bianchi et al., 2023). These factors influence both vulnerability to and resilience against CPTSD.
Risk factors, such as exposure to severe or prolonged trauma, particularly during critical developmental periods like childhood, significantly heighten the susceptibility to CPTSD (Karatzias et al., 2019). Additionally, a lack of social support, maladaptive coping mechanisms, unresolved grief or loss, underlying mental health conditions, biological predispositions, and re-traumatization further exacerbate the risk.
Conversely, protective factors serve as buffers against the detrimental effects of trauma and foster resilience in individuals (Campodonico et al., 2021). Strong social support networks, encompassing relationships with family, friends, peers, or community members, provide crucial emotional and instrumental support.
Effective coping strategies, including problem-solving skills, emotion regulation techniques, mindfulness practices, and seeking social support, also empower individuals to navigate traumatic experiences more effectively (Greenberg, 2022). A sense of purpose and meaning in life, access to timely and evidence-based mental health services, and adopting healthy lifestyle choices are additional factors that strengthen resilience.
By recognizing and addressing these risk and protective factors, you will be able to identify and treat CPTSD more effectively.
CPTSD vs. PTSD: Understanding the Differences
Complex post-traumatic stress disorder has been considered a subtype of PTSD, yet they possess distinct features that need different approaches in diagnosis and treatment and are now seen as separate conditions (Cloitre et al., 2014).
While both result from traumatic experiences, CPTSD is caused by chronic, cumulative trauma that overwhelms an individual’s coping mechanisms (Stadtmann et al., 2018).
Unlike PTSD, CPTSD manifests with a broader symptom spectrum, extending beyond re-experiencing and arousal symptoms to encompass disruptions in self-organization, including emotion dysregulation and impaired relationships (Cyr et al., 2022). It also tends to be more chronic and severe, persisting over time and profoundly impacting various aspects of life, contrasting with the fluctuating nature of PTSD symptoms.
CPTSD deeply affects identity and interpersonal dynamics, which undermines trust building and boundary setting (Shevlin et al., 2018). Treatment for CPTSD, therefore, often requires longer-term, comprehensive interventions addressing broader symptomatology and underlying issues.
Understanding these conditions and their differences is crucial for tailoring interventions and providing effective support to individuals grappling with the complexities of trauma-related disorders (Shevlin et al., 2018).
CPTSD vs. BPD: How Do They Differ?
Another condition that requires analysis and comparison to CPTSD is borderline personality disorder (BPD). It is important to make an accurate differential diagnosis between the two conditions. So, let’s compare.
Firstly, although CPTSD typically stems from prolonged trauma, as we’ve discussed above, BPD arises from various factors, including genetics and early life experiences (Kulacaoglu & Kose, 2018).
Secondly, symptoms overlap in emotion regulation and interpersonal challenges, but CPTSD primarily involves trauma-related symptoms like flashbacks and hypervigilance, while BPD encompasses broader instability, fear of abandonment, and self-image issues (Cyr et al., 2022).
In addition, in CPTSD, disruptions in identity and relationships result from trauma, whereas BPD involves identity instability and intense but unstable relationships.
Treatment approaches also differ in that CPTSD often responds to trauma-focused therapies like Cognitive-Behavioral Therapy, while BPD responds better to treatments such as Dialectical Behavior Therapy and medication (Cloitre et al., 2014). Lastly, while CPTSD may improve with trauma-focused therapy, BPD tends to be chronic, necessitating ongoing treatment.
In order to best support your clients, you may want to learn more about differentiating these disorders to provide tailored interventions for individuals’ specific needs. You may want to watch this informative five-minute Psych2Go clip to learn more.
Difference between CPTSD and BPD - Psych2Go
6 Therapeutic Approaches to Complex Trauma
Treating complex trauma requires holistic therapeutic approaches that address the multifaceted nature of the disorder and its impact on various aspects of an individual’s life.
Here are several therapeutic approaches commonly used:
TF-CBT is a structured, evidence-based therapy specifically designed to address trauma-related symptoms (Mannarino et al., 2014). It combines cognitive-behavioral techniques with trauma-focused interventions to help individuals process traumatic memories, challenge maladaptive beliefs, and develop coping skills for managing symptoms.
It will be particularly helpful if you are treating traumatized children (Pollio et al., 2014).
2. Eye movement desensitization and reprocessing (EMDR)
EMDR is a psychotherapy approach that involves bilateral stimulation such as eye movements, taps, or sounds while recalling distressing memories (De Jongh & Hafkemeijer, 2023).
This technique will allow your clients to reprocess their traumatic experiences, reduce emotional distress, and integrate adaptive beliefs and emotions.
This EMDR Worksheet for therapists provides four categories of common negative cognitions and example positive counterparts that your client can use as replacements.
3. Internal family systems (IFS) therapy
IFS offers a promising approach for treating CPTSD by helping individuals identify and differentiate their internal “parts” while facilitating the safe processing of traumatic memories and emotions held by these parts (Lucero et al., 2018).
It aims to integrate all parts into a cohesive internal system, promoting healing and growth in the aftermath of trauma. You may find it helpful to integrate IFS with other trauma treatments, such as EMDR or art therapy, for a more comprehensive treatment approach (Kolodny & Mazero, 2022).
4. Sensorimotor psychotherapy
This approach integrates the cognitive, emotional, and physical processing of trauma (O’Shea Brown, 2021). It emphasizes mindfulness techniques, body awareness, and somatic interventions to help individuals regulate their nervous system arousal and release trauma-related tension stored in the body. It is proving to be a promising therapeutic approach to CPTSD (Classen et al., 2021).
5. Acceptance and commitment therapy (ACT)
ACT combines mindfulness and acceptance strategies with commitment and behavior change techniques (Walser & Hayes, 2006). You can use this approach to help your clients develop psychological flexibility, clarify personal values, and take committed action toward building a meaningful life despite trauma-related challenges (McLean & Follette, 2016).
6. Art therapy
Art therapy offers a creative and nonverbal approach to addressing the complex symptoms of CPTSD (Spiegel et al., 2006). It allows individuals to express and process their traumatic experiences through various artistic mediums, fostering self-awareness, emotional regulation, and healing (Brenner-Malin, 2015).
In her TED talk, Deena Lynch shares her experience of CPTSD and how she used creative tools to support her own mental health.
How art and music helped me overcome my complex PTSD
These therapeutic approaches can be tailored to meet the unique needs and preferences of individuals with complex trauma, offering hope, healing, and empowerment on their journey toward recovery. It’s essential for therapists to collaborate with clients and treatment teams to create a treatment plan that addresses their specific symptoms, strengths, and goals.
7 Worksheets for Clients With CPTSD
Providing clients with CPTSD with worksheets can be a helpful adjunct to therapy, as it allows them to engage in structured activities outside of sessions and deepen their understanding of their experiences (Müller-Engelmann et al., 2016). Here are several types of worksheets that can be beneficial for clients with CPTSD:
Trauma timeline
A trauma timeline worksheet allows clients to map out significant events and experiences throughout their lives, including both traumatic incidents and positive moments. This can help clients identify patterns, triggers, and themes related to their trauma history, as well as track their progress in therapy.
Use our Childhood Timeline worksheet to help your client track developmental wounding events and patterns that may be causing their present challenges.
Grounding techniques
Grounding techniques provide clients with helpful strategies for managing distressing symptoms, such as flashbacks, dissociation, and anxiety.
These may include sensory grounding exercises, mindfulness practices, or self-soothing techniques that help clients stay present and regulated during times of distress. Our Grounding and Centering worksheet will help your client locate and play with their center of gravity while keeping them in the present moment.
Emotion regulation
Emotion regulation can help clients identify and understand their emotions, develop awareness of emotional triggers, and learn effective strategies for managing intense feelings.
This may include exercises for identifying primary and secondary emotions, practicing emotion regulation skills, and creating personalized coping plans. This Emotion Regulation Worksheet aims to help clients identify and manage their emotions and choose alternate ways of responding.
Cognitive restructuring
Cognitive restructuring assists clients in challenging and reframing maladaptive thoughts and beliefs associated with their trauma experiences.
You can use our Cognitive Restructuring Worksheet to help your clients identify cognitive distortions, evaluate the evidence for and against negative beliefs, and generate more balanced and adaptive perspectives.
Self-compassion
Self-compassion worksheets can be used to encourage clients to cultivate kindness, acceptance, and understanding toward themselves, especially in the face of trauma-related shame, self-blame, or criticism.
These worksheets may include exercises for practicing self-compassionate self-talk, writing compassionate letters to oneself, and developing a self-compassion plan. The “I Will Survive” worksheet will help your client evaluate their coping skills, support resources, and how to access these in the face of challenges.
Value clarification
Value clarification exercises help clients identify their core values, priorities, and aspirations in life, which can serve as a guide for healing and recovery.
Clients can explore questions about what matters most to them, what gives their life meaning and purpose, and how they can align their actions with their values.
This Personal Values worksheet will help your client identify what’s most important to them and how to focus their energy to support those values.
Self-care
Self-care prompts offer clients opportunities to explore and implement activities that promote relaxation, self-soothing, self-nurturing, and wellbeing. This may include exercises for creating self-care routines, scheduling pleasurable activities, and practicing relaxation techniques such as deep breathing or progressive muscle relaxation.
The Self-Care Check-In worksheet is a quick way to evaluate where your client is and what prompts they may need to do more self-nurturing.
You can use these worksheets in conjunction with therapy sessions to enhance learning, self-reflection, and skill building for your clients with CPTSD (Müller-Engelmann et al., 2016). It is important, however, that you tailor worksheets to meet the needs and preferences of each client, providing guidance and support as needed throughout the process.
A Path Forward: From CPTSD to Post-Traumatic Growth
Post-traumatic growth refers to the transformative journey some individuals undertake following traumatic experiences (Dagan & Yager, 2019).
It is characterized by the manifestation of positive psychological changes and personal development post-trauma.
Helping your client move from CPTSD to post-traumatic growth requires a comprehensive and intentional strategy (Jayawickreme et al., 2021). This process necessitates a multifaceted approach, encompassing therapeutic interventions aimed at addressing trauma-related symptoms, fostering resilience, and cultivating adaptive coping mechanisms.
By providing a supportive and empowering environment, you can facilitate the exploration of trauma narratives, reframing adversity as an opportunity for growth and self-discovery (Coleman et al., 2021). Additionally, interventions focusing on enhancing self-awareness, promoting self-compassion, and fostering a sense of meaning and purpose can facilitate the cultivation of post-traumatic growth.
By taking intentional steps toward healing and self-discovery, those with CPTSD can navigate the challenges of trauma and emerge with resilience, authenticity, and a renewed sense of meaning in their lives (Dagan & Yager, 2019).
With the hands-on tools and exercises you’ll receive as part of the course content, you’ll be all set to help your CPTSD clients address the challenges they may be facing in the wake of their trauma.
Understanding complex trauma and its recovery, particularly in the context of CPTSD, is crucial amid the rising global trauma landscape. Therapists must understand CPTSD to effectively aid their PTSD clients.
By recognizing the nuanced manifestations and tailoring interventions to address multifaceted symptoms, you can guide your clients from distress to post-traumatic growth.
Comprehensive approaches, like trauma-focused cognitive behavioral therapy, eye movement desensitization and reprocessing, internal family systems therapy, and other modalities, can be used to empower your clients on their journey toward healing and resilience.
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About the author
Susan McGarvie, Ph.D., is a writer, researcher, and therapist in private practice. With more than twenty years' experience working in the health and NPO sectors, her research, writing, and work have focused on supporting practitioners to better manage stress and create a balanced sense of wellbeing.
As we face the worrying increase of environmental events, pandemics, and wars across the globe, the topic of trauma is extremely relevant across various contexts.
Complex post-traumatic stress disorder has been considered a subtype of PTSD, yet they possess distinct features that need different approaches in diagnosis and treatment and are now seen as separate conditions (Cloitre et al., 2014).
