What is CPTSD and do I have it?
Hi I’m Sarah! I’m a Manchester psychotherapist, working online via Zoom throughout the UK and Europe.
I specialise in working with childhood trauma and CPTSD.
Hi I'm Sarah! I'm a Manchester psychotherapist, working online via Zoom throughout the UK and Europe.
I specialise in working with childhood trauma and CPTSD (also known as complex trauma or complex ptsd).
Let's start with the basics:
What is trauma?
Trauma is widely understood to be a traumatic event or experience that represents a threat to life or bodily integrity (safety of the body) or a belief that such a threat exists.
Traumatic means overwhelming or upsetting; when a distressing event happens we often feel unable to cope or manage our emotions or physical symptoms and struggle with daily life.
So if someone threatens to harm this is traumatic because you have no way of knowing whether it is an empty threat or a real 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 which means that what is scary for you may not affect me in the same way.
Childhood Trauma
Children are also far more likely to become 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 unlikely 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. To learn more about the different types of childhood trauma click here
Despite no official diagnosis of complex trauma 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. Knowing that I have worked with and helped other complex trauma survivors and that they have learned to manage their triggers and their emotions can be enormously comforting when entering into therapy.
What is CPTSD?
If you‘re looking for information on CPTSD or searching for a psychotherapist who works with complex trauma online 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' recently, I got redirected to search for PTSD so it's clear that CPTSD is not yet a mainstream search term.
What is Complex trauma?
So let's start with the basics. CPTSD, also known as complex trauma, complex ptsd or sometimes developmental trauma, is not yet an official diagnosis.
Is CPTSD a diagnosis?
One of the main books for diagnosing mental health conditions worldwide is a manual called the DSM (Diagnostic and Statistical Manual of Mental Disorders). It is written by an organisation called the American Psychiatric Association and outlines all mental health issues that are considered to be current. It does not yet outline CPTSD or complex trauma as an individual diagnosis, but includes it under the more general term of PTSD. The DSM is used and referred to by psychiatrists, doctors and other health professionals throughout the UK.
The DSM is now on its 5th edition and is updated periodically; sometimes terms are also updated. So what was once called manic depression is now known as bipolar.
The DSM includes CPTSD or Complex PTSD 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 the difference between PTSD and CPTSD?
A common differentiation between PTSD & C-PTSD is the following: PTSD stems from a single incident (an accident, a violent attack, a sexual assault, a natural disaster such as an earthquake, or major disaster such as a fire or terrorist attack).
CPTSD or complex trauma stems from a series of events 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.
What is the treatment for CPTSD?
For people who are looking for complex trauma treatment, the situation can be confusing. They might wonder whether they need a diagnosis before getting started or whether they need a particular type of psychotherapist or counsellor? Do they need to see their doctor? A psychiatrist? It may not be clear where to start.
There are various treatment options available for CPTSD offered by the NHS in the UK known as 'Trauma-Focused Psychological Treatments, which include Trauma-Focused Cognitive Behavioural Therapy (or Trauma Focused CBT), drug treatments such as anti depressants (also known as SSRI's or Selective Serotonin Reuptake Inhibitors) and EMDR (which stands for Eye Movement Desensitisation and Reprocessing) and involves rapid eye movements with the aim of reducing the severity of the traumatic memories.
In the UK there are a large number of therapists who work privately, which affords you more control of who and how you work with CPTSD. Private therapists may work in various different ways and some will also offer EMDR.
There are also third sector therapy services such as charities who may offer therapy or support. PTSD UK is a UK charity aiming to raise awareness of PTSD and CPTSD and support survivors.
Do I need a CPTSD diagnosis to get therapy?
As in many areas, it is rare that all trauma 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 through a 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 but I may suggest diagnoses for informational purposes if it feels relevant.
Do I need a diagnosis of CPTSD to get therapy?
As mentioned above, being given the diagnosis of complex trauma even for informational purposes can be very validating for people who have felt misunderstood and disbelieved.
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 symptoms of CPTSD?
With all of the above in mind, health professionals who use the term CPTSD or complex trauma are normally talking about symptoms and emotional symptoms in the following areas:
CPTSD causes emotional flashbacks
CPTSD flashbacks are not always the visual flashbacks that are associated with PTSD and in fact flashbacks can also be auditory or olfactory (smell) in format. They can be emotional flashbacks which is a phrase used by Pete Walker in his book ‘From surviving to thriving'. These might also known as amygdala hijacks.
This 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 Complex PTSD may experience the current situation as if it were the original situation. This can sometimes be accompanied by trauma memories or other upsetting memories from their past.
They can also experience the same overwhelming and crushing emotions that they experienced as children and react in ways that seem confusing to someone who is grounded in the present. Their reactions may not make sense or look very extreme. They might experience strong feelings of anger, feelings of fear, feelings of distrust or feelings of isolation or shame.
They may experience feelings of panic or have a panic attack or experience physical sensations such as a racing heart or crying. This can be confusing to witness and can be viewed as an out of control or over the top response to a minor situation. They may also ‘shut off' or be unable to speak which are also known as dissociative symptoms.
CPTSD causes disassociation
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 feelings and experiences but can cause problems in every day life especially when triggers are unrecognised because then it is difficult to control or understand.
Alongside dissociation people can also feel disconnected from their bodies and cut off from their feelings. This can cause emotional numbness and difficulty accessing their feelings. This can be compounded by growing up in families who don't talk freely about emotions or provide emotional support. Also known as emotional neglect or childhood emotional neglect or CEN, you can find out more about this here
CPTSD causes relationship difficulties
CPTSD can cause relationship problems which can severely affect your quality of life, partly because of the likelihood of the above symptoms, often because people are in still close contact with their abusers (particularly if they were family members), and because they are not able to trust others or are overly invested in relationships too early and are let down.
Everyday life can be retraumatising for example if people have frequent interactions with their abusers. Sometimes relationship difficulties are a result of someone standing up for themselves and encountering push back, manipulation or other punishment from the abuser.
People who grew up in dysfunctional families 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 emotionally abusive or emotionally neglectful relationships (although they are of course not responsible or to blame for these).
CPTSD causes a negative self image
Although other issues can cause negative self image or thoughts of guilt and worthlessness, people who experience complex trauma 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.
CPTSD causes 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.
CPTSD causes sleep problems
Alongside causing sleep disturbances such as waking up or being unable to sleep, people may also experience nightmares, intense dreams, frightening dreams or relive the horrific event through nightmares.
In my experience, nightmares improve as people start to make sense of what happened to them and allow themselves to acknowledge how traumatic their situation was. Allowing themselves to feel some of the blocked off emotions or get support from people that care about them helps people to feel less alone and less hopeless and gradually the nightmares decrease.
CPTSD affects physical health
Research has been done into the correlation between childhood abuse and poor physical health and even seemingly unrelated issued may be linked to the stress caused by feeling under threat and the stress response in the body.
Although all medical conditions should be investigated if possible, some problems such as IBS and other gastrointestinal difficulties, some chronic pain, and some types of chronic fatigue or fibromyalgia may have links to childhood trauma.
How do I find a therapist that works with CPTSD?
When looking for CPTSD therapy, 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.
CPTSD Treatment in the UK
Therapists in the UK do not always specialise which can make it difficult to find people who are a trauma expert or who specialise in complex trauma or emotional abuse.
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 and what kind of results they get. Although complex trauma can be debilitating, it is possible to heal and get good results in psychotherapy.
Trauma informed therapy
Not all courses or counsellors 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 appropriate to them.
They should not feel obliged to work faster than they can or talk about upsetting experiences if they are not ready.
I do not believe that all approaches are suitable for CPTSD clients. I often hear from clients that they felt rejected or abandoned by therapists that take a blank slate approach and say very little or who won't answer client questions.
Relational therapy for relational trauma
Most traumatised children experienced trauma within their relationships. This meant that the very people they were supposed to trust were the ones who hurt them, and often repeatedly.
My own approach is a relational one, which means I interact with my clients, I answer questions, I will tell them what I think or feel about specific things since so many clients have suffered relational trauma (damage has been done within a relationship).
The type of therapy is generally considered less important than whether the client likes the therapist and feels safe around them. Having said this, I do believe many clients benefit from both clear explanations around aims in therapy and an ability to interact with the therapist in a normal way. Some therapies don't allow for these normal interactions because for example they don't allow the therapist to talk about themselves at all. In my mind this can be hurtful for the client and mean they have less experience of normal interactions.
Some clients have previously tried counsellors who would not speak for whole sessions or who refused to explain a facial expression or talk about how the client experienced the psychotherapist.
For clients who have lived in an inner world that was scary and experienced 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.
I am now working online, which means no matter where you are in the UK or Europe, you have the option to work with me. To book a free 15 minute call to find out how I can help you click here, without even picking up the phone.