What is CPTSD and do I have it?
MY NAME IS SARAH LEE AND I'M A PSYCHOTHERAPIST WORKING IN MANCHESTER CITY CENTRE
If you‘re looking for information on CPTSD or searching for a therapist who works with complex trauma either Manchester or another area, you might be frustrated by the lack of information available. Or perhaps Google even suggested you were searching for the wrong thing. In fact when I tried searching ‘CPTSD Manchester’ I got redirected to search for PTSD so it’s clear that CPTSD is not yet a mainstream search term.
So let’s start with the basics. CPTSD, also known as complex trauma or complex ptsd or also sometimes developmental trauma, is not yet an official diagnosis. What does this mean? This means that a manual called the DSM (Diagnostic and Statistical Manual of Mental Disorders) which is written by an organisation called the American Psychiatric Association and outlines all mental health issues that are considered to be current does not yet outline CPTSD as an individual diagnosis. The DSM is used worldwide and is referred to by psychiatrists, doctors and other health professionals throughout the UK.
The DSM is now on its 5th edition and is updated periodically; for example passive aggressive is no longer considered a personality disorder (and my trainer joked that when it was removed they wiped out half the English population in one fell swoop!) Sometimes terms are also updated. So what was once called manic depression is now known as bipolar.
The DSM includes CPTSD in the wider diagnosis of PTSD. This means it is considered a form of PTSD (post traumatic stress disorder) and not a separate diagnosis.
What is trauma?
Trauma is widely understood to be an event or experience that represents a threat to life or bodily integrity or a belief that such a threat exists. So a threat that someone will harm you can be traumatic because you have no way of knowing whether it is a threat or an intention to harm you. Bodily integrity normally refers to sexual assault so whilst the assault may not be considered violent your personal boundaries are violated and it is traumatic.
It is worth noting that trauma is subjective so that what is scary for you may not affect me in the same way. Children are also far more susceptible to being traumatised than adults. They often have no physical, emotional or financial independence. Where an adult can in some cases walk away from a situation, a child is unlike to have that option. This becomes particularly difficult therefore when abuse or neglect comes from within the family because the child often has no means of escape.
Despite no official diagnosis existing, the term is widely used in mental health circles and is gaining recognition. This is driven partly by experts in trauma such as Van der Kolk, Hermann, Rothschild (who are at once authors, researchers and practitioners in the field of trauma) and partly by mental health services consumers. Many clients resonate very strongly with the term CPTSD in a way that they do not with PTSD. I have seen that feeling understood can be a critical part of the recovery process and the concept that there exists other people who have been through similar experiences and come out the other side can be a very powerful one to clients.
What is the difference between PTSD and CPTSD?
A common differentiation between PTSD and CPTSD is the following: PTSD stems from a single incident (an accident, a violent attack, a sexual assault, a fire, an earthquake). CPTSD or complex trauma stems from multiple and/or repeated incidents. It is often found in individuals who experienced abusive or neglectful childhoods or who experienced abusive relationships as an adult, people who have lived in war zones or otherwise unstable environments or those who have been trafficked.
Where to start?
For people who are starting to look for help, the situation can be confusing. They might wonder whether they need a diagnosis before getting started or whether they need a particular type of practitioner? Do they need to see their doctor? A psychiatrist? It may not be clear where to start.
Is a diagnosis necessary?
As in many areas, it is rare that all experts are in agreement concerning approaches and treatment methods. Some people are strongly in favour of diagnosis. If you are looking for a diagnosis then you would need to see a psychiatrist. Either from referral by your GP or privately depending on which route you take. Some people mistakenly believe a diagnosis is somehow ‘required’ before starting therapy. It isn’t. I don’t provide official diagnoses to clients (despite 4 years of study I am not qualified to do so, and diagnosed can overlap or occur with other diagnoses) but I will mention diagnoses for informational purposes if it feels relevant.
One argument against diagnosis is the danger that clients can feel trapped by them and feel unable to change beyond their boundaries or believe that there is no possibility for improvement or relief from symptoms. I do think that a diagnosis can allow people to read and educate themselves in specific areas which can be very empowering; it is far more useful to read about depression than OCD for example if that’s what you are struggling with (unless there is a crossover). It can also happens that a client feels very strongly that a certain diagnosis fits their experience and the psychiatrist disagrees and won’t sign off on it. This can be retriggering and retraumatising and the benefit of fighting for what you believe to be a correct diagnosis should be weighed up with the cost to achieve one (this may be relevant where particular medications would be prescribed for example such as in Bipolar).
What are the signs of CPTSD?
With all of the above in mind, health professionals who use the term CPTSD are normally talking about symptoms that include:
CPTSD flashbacks are not always the visual flashbacks that are associated with PTSD (and in fact flashbacks can also be auditor or olfactory in format). They can be emotional (also known as amygdala hijacks). This often manifests as ‘disproportionate’ reactions to specific events or triggers (which may not be known to the person and compounds the confusion). So if someone uses a specific word or an argument occurs, someone with CPTSD may experience the current situation as if it were the original situation. They may experience the same overwhelming and crushing emotions that they experienced in the past (often as children) and react in ways that seem confusing to someone who is grounded in the present. Their reactions may not make sense, they may be viewed as out of control or over the top, they may ‘shut off’ or be unable to speak.
It’s common that I explain disassociation to a client and they exclaim ‘oh, I didn’t realise that was a thing’ or ‘I thought it was just a weird thing that I did’. Disassociation is a shutting off process that occurs in high stress and overwhelming situations. People are often unable to think or sometimes speak. They might call it ‘zoning out’ or ‘spacing out’. Others might get annoyed or angry if they feel the person is ignoring them or not paying attention. It might be described as if the person were watching events happen to themselves or as if watching tv as if were no part of their real life. It is a coping technique to protect the body from overwhelming feeling and experiences but can cause problems in every day life especially when triggers are unrecognised because then it is difficult to control or understand.
CPTSD causes relationship problems, partly because of the likelihood of the above issues, often because people are in still close contact with their abusers (particularly if they were family members), and often because they are (understandably) not able to trust others or are overly invested in relationships too early and are let down. People who grew up in dysfunctional families (as is often the case with CPTSD) do not know how to communicate, may be scared to express their thoughts or feelings and often have very skewed ideas of what a healthy relationship looks like. They are therefore susceptible to abusive or emotionally neglectful relationships (although they are of course not responsible or to blame for these).
Negative self image
Although other issues can cause negative self image or thoughts of guilt and worthlessness, people who experience CPTSD often find their self image is very damaged. They may struggle to see themselves as having any worth, may imagine that nobody likes them, may sabotage relationships because they feel so worthless, they may struggle with overwhelming feels of shame and not being good enough (and the shame is often difficult to recognise so they may just feel a ‘bad feeling’ or feel like a bad person). They may feel guilt even though they have not done anything or if they do try and distance themselves from unhealthy relationships this may also trigger guilt and shame.
Difficulty with emotions
Many clients struggle with emotions, often struggling to recognise them to express them or to tolerate them. For people with CPTSD their emotions can feel enormous and they may have suicidal thoughts as means to escape these overwhelming feelings. Recognising, expressing and tolerating emotions are skills that can be learned and with time clients gain experience and are able to work with their emotions instead of seeing them as ‘bad’ or to be avoided or ignored.
How do I find a therapist who works with CPTSD?
When looking for a therapist, it is important to remember that there is currently no legislation in the UK to protect terms such as therapist, counsellor, psychotherapist or psychologist. Training and training standards are varied and whilst most therapists take their responsibilities very seriously it is important to be judicious when starting your search. Training can vary between 2-4 years + and can be at different academic levels from diploma to degree level, to masters level to phd level. There is currently no requirement to be part of a membership body, all membership is voluntary.
The UKCP (one of the main bodies of which I am a member) requires 4 years at masters level to be considered a psychotherapist. The BACP (the largest voluntary body currently) requires a minimum of 2 years study and does not differentiate between counselling and psychotherapy. There are various other bodies with differing requirements.
Therapists in the UK do not always specialise (it is beginning to change and it in the US it is much more common). You can ask any prospective therapist if they have any specific area of interest to see if it matches what you are looking for. Therapists who specialise in an area are likely to be focussing their ongoing training, practice with clients and reading in that area which means they will likely have more experience with CPTSD. Since many therapists do not specialise, look for words such as ‘trauma informed’ ‘emotional abuse’ or ‘dysfunctional backgrounds’ in their websites or online profiles. Don’t be afraid to ask what experience they have with CPTSD or developmental trauma.
Not all courses or therapists have experience with trauma or complex trauma. I encourage traumatised clients not to trust me. I never ask for specific details of trauma as this can be retraumatising and exacerbate symptoms. I encourage clients to go slowly and see how they feel in our sessions and afterwards. They should feel supported and heard and feel as if they are learning new skills and coping mechanisms at a pace that feels a propitiate to them. They should not feel obliged to work faster than they can or talk about upsetting experiences. This applies to all therapists. Some approaches are not suitable for all clients. I prefer a relational approach (which means I interact with my clients, I answer questions, I will tell them what I think or feel about specific things) because so many clients have suffered relational trauma. Some clients have previously tried therapists who would not speak for whole sessions or who refused to explain a facial expression or talk about how the client experienced the therapist. For clients who have lived in an inner world that was scary and experience others who were scary it is critical that they can check their assumptions and ability to read things with me. They need to be encouraged to speak not abandoned to fill a whole session without support. They need someone to notice when they are struggling or have switched off and adjust accordingly, they don’t need a formulaic approach.
If you would like to contact me to discuss your requirements, I offer a free 20 minute phone consultation. You can reach me here