Managing Complex Post-Traumatic Stress Disorder

Greetings and salutations! My name is Andy Semler, and I will be discussing
treatment options for managing the symptoms of complex post-traumatic stress disorder,
hereafter abbreviated CPTSD. We will look at the causes and symptoms of
CPTSD; explore the current guidelines for effective treatment, with a closer look at
a few of the specific elements recommended by experts; and address some of the current
debate surrounding these guidelines. Recovery from Complex Post-Traumatic Stress
Disorder (CPTSD) requires restoration of control and agency to the traumatized person through
a phase-based approach that focuses on emotional skills-building, processing trauma, and setting
goals for the future. First we will look at the causes of CPTSD. Many people are familiar with the popular
image in the media of the soldier who experiences a violent life-threatening situation and comes
home traumatized � that would be the traditional understanding of PTSD. However, this is not the only form trauma
can take in a person�s life. Many people are traumatized within a more
complex environment involving sustained exposure to the threat on their well-being. They feel entrapped, helpless to escape or
improve their situation, and over time become conditioned to view themselves as helpless,
even in situations where there is no threat. The most studied example is child sexual abuse,
where the development of healthy relationship skills is interrupted by trauma. Other situations in which a person can become
trapped with their abusers include violent domestic relationships, being a prisoner of
war or a refugee, being a victim of human trafficking including slavery and prostitution,
having a chronic illness that involves long-term suffering or painful medical treatments, and
even involvement in particularly strict religious traditions or cults. The end result is that the trauma causes a
disruption in development, or a reconditioning, of a person�s sense of themself and their
placement in the world. Some of the symptoms of CPTSD overlap with
PTSD, but the total complexity and severity goes above and beyond. This slide and the next contain a lot of technical
terms, so let�s look at what they really mean. �Prominent dissociation� involves feeling
estranged from oneself, from others, and from one�s surroundings; this can even lead to
episodes of amnesia. The �difficulties with attention� go above
and beyond mere distraction, to a profound difficulty to concentrate or understand a
situation. �Alterations in the regulation of affective
impulses� is a fancy way of saying that the person has difficulty managing anger,
is impulsive, or is engaging in self-harm, due to their inability to sooth intense negative
emotional states. �Somatization and medical problems� can
include chronic pain or other stress-related medical complications. The victim�s �perception of the perpetrator�
may be altered into a dysfunctional perception of or relationship with that person. As a result of this reconditioning, they may
experience a general �dysfunctional or avoidance of relationships�. This involves a chaotic approach to or preoccupation
with relationships, in which they may feel they are unable to trust others or develop
intimacy. They have come to view others as ultimately
self-serving and out to take advantage of them through any means necessary. The internalization of abuse messages lead
to an �altered self-perception� in which their concept of self is dominated by feelings
of guilt and shame and utter worthlessness as a person. Their �systems of meaning� may be altered,
resulting in a damaged belief system or feelings of being permanently negatively changed by
the event. This can lead to a sense of hopelessness at
finding someone who will understand them, or despair of ever being able to recover. Since CPTSD is the prevention of development
or the deterioration of emotional and relational skills, treatment seeks to build these skills
in addition to processing the trauma itself. The International Society for Traumatic Stress
Studies has developed guidelines for therapists which they update regularly, based on their
periodic reviews of research and their own surveys of therapeutic experts on CPTSD. They advocate a phase-based approach to treatment,
in which the patient first builds up emotional and relational skills, which equips them to
deal with the trauma in a way they were previously unable to, before finally restructuring their
life in a way that takes advantage of therapeutic gains. Treatment length is an aspect in need of further
study, but it has been recommended 9-12 months for the first two phases of treatment, with
the third phase eventually tapering off over 6 months. Phase 1 of treatment is about stabilizing
the patient emotionally, establishing a treatment plan, and building up emotional skills. The very first step is to address immediate
safety concerns to the patient: address any suicidality or self-harm that may be present. Discover unsafe elements in their environment
that perpetuate trauma, and if possible remove the patient from those situations. If the patient must remain in an dangerous
situation, establish a safety plan that takes advantages of social and community resources. Treatment plans for substance abuse, as well
as prescribing medication, may be appropriate. Once the patient has been stabilized in this
manner, the therapist can then educate them on many of the things I am including in this
presentation. This psychoeducation will help them to better
understand how trauma has impacted their development; that CPTSD is something they experience, not
who they are as a person. Psychoeducation will also help them take an
active role in developing a treatment plain tailored to their personal needs. Integrated with all of this is emotional and
relational skills building, which I will go into in more detail later on. Phase 1 is the longest and most important
phase, with some patients able to continue improvement on their own after completion
of this stage. As mentioned earlier, some of the symptoms
of CPTSD include distrust of other people and a belief that people are fundamentally
out to abuse or take advantage of the patient. This can make the patient particularly sensitive
to any perceived negative attitudes or opinions from the therapist. The therapist must cultivate the therapeutic
alliance most scrupulously, in order to provide a safe environment for the patient to address
their struggles and anxieties. Over time, the patient can come to trust their
working relationship with the therapist, and see that the potential for other successful
relationships is possible. Skills Training in Affect and Interpersonal
Regulation was designed specifically for the first phase of CPTSD treatment. It covers 7 different areas of emotional and
relational skills. Many people survive trauma by disconnecting
themselves from overwhelming negative emotions. However, this is sort of shutting down not
useful in normal situations where a wide range of emotional experiences is healthy. First, the patient needs to learn emotional
awareness. The patient needs to learn how to name, understand,
and describe emotions. Second, they can begin building skills to
help them regulate uncomfortable emotions, bringing them into a manageable range. They can learn what coping mechanisms produce
desired results and which are self-defeating. Third, they can learn how to engage with distressing
situations in a productive way. Everyone experiences stress from time to time,
and by learning to apply effective coping skills, the patient can regain a sense of
control in their life. Now that they�ve built up internal skills,
the next 4 step focus on external applications in relationships with others. Again, the first step is to understand relationship
patterns that play out in the patient�s life, and identify ways in which they have
set up self-fulfilling interpersonal schemas. Second is to explore ways of interacting with
others through role playing interpersonal scenarios with the therapist. This is where the therapeutic alliance is
so important � the patient must be able to trust that the therapy will not result
in emotional harm caused by the therapist. The next step is to explore more challenging
interactions in role-play, allowing the patient to exercise agency in healthy boundary-setting. Finally, the patient can use this gained sense
of agency to adopt a flexible approach to relationships of many different varieties,
no longer reproducing the same self-defeating patterns as before. Expert consensus and several trials agree
that patients benefit from building up emotional skills they are lacking, in order to be better
equipped to handle the stress of revisiting and processing trauma in Phase 2 of the ISTSS
treatment guidelines. Patients are more likely to drop out of therapy
if forced to confront traumatic memories without first focusing on emotional skills development. As you can see in the graph, the yellow line
denoting the group without STAIR experienced worse mood regulation during treatment, which
is one possible cause for increased drop-outs. You can also preview the importance of exposure
therapy in Phase 2 on sustained emotional gains. ISTSS guidelines indicate mindfulness as a
possible supplement to professional therapy. There are 5 basic aspects to mindfulness which
have been examined for effectiveness with dissociative aspects of PTSD and CPTSD. The most helpful aspect was �nonreactivity�,
that is the observation of one�s own emotional states without being swept away by them. Describing, acting with awareness, and non-judging
may also be beneficial. �Observing�, or the direction of one�s
focus to one�s current physical state, should be avoided, as it may lead to a worsening
of dissociative symptoms. After approximately 6 months at Phase 1, the
patient may be ready to transition into Phase 2. Exposure therapy is what most people are familiar
with as the treatment for traditional PTSD. This involves simulating the trauma or otherwise
emotionally re-experiencing it through narration, within a safe environment. The goal is to rework the patient�s emotional
response to the trauma in a way that is constructive to their sense of self. Exposure therapy is an important and effective
part of a phase-based treatment plan. As you can see in the graph, the group that
combined STAIR with exposure therapy experienced sustained improvements in the 6 months following
their exit of treatment. Exposure therapy often involves narration
of the traumatic event in safe environment, or otherwise revisiting the trauma through
symbolism or artistic expression. The purpose is to recondition the patient�s
emotional response to traumatic stimulus. The patient may experience grief, shame, or
rage, and spend much of Phase 2 processing through these emotions. They may also take active steps to resolve
traumatic situations or set healthier boundaries with abusers. When following emotional skills-building,
the patient rarely experiences re-traumatization during the exposure process. Even still, the therapist should be vigilant
for a sudden increase in symptom severity or even suicidality, and return to Phase 1
as needed for additional emotional skills building. Traumatized individuals often have fragmented
memories of the situation, and their self-narrative emphasizes their personal helplessness. Many times they get �stuck in the past�,
unable to visualize a healthier future for themselves. The purpose of exposure therapy is to reintegrate
the traumatic memory into one�s autobiography in a way that is coherent and compassionate,
using language that conveys resilience and transformation. For example: in my own life stories, I depict
the trauma I have survived as constructive to how I became a stronger person today, even
while condemning those who caused me harm. A coherent self-narrative gives the patient
a sense of control over their life and sets a positive direction for their future. After having spent 9-12 months in Phases 1
& 2, the patient may now proceed to Phase 3. This is the opportunity for the patient to
wrap up what they�ve learned so far and apply it toward their approach to the future. Some individuals with CTPSD may have never
believed recovery was possible, and so the idea of setting personal goals and working
toward them is unfamiliar to them. Some possible areas in which they may create
plans includes education and employment, recreation and hobbies, relationships and social support
networks, and so on. This is also a time for the patient to identify
any future therapeutic needs, such as identifying whether they need ongoing lower-intensity
treatment, and how they would know if they need any �booster sessions� in the future
as necessary. There has been some push-back against CPTSD
as a distinct form of PTSD since the concept was first introduced in the 1990s. Many PTSD experts don�t think the additional
symptoms proposed for CPTSD are sufficient to warrant a separate diagnosis, instead seeing
it as regular old PTSD taken to a more extreme level. Compared to the traditional approach to PTSD,
the ISTSS phase-based approach may draw treatment out much longer than is necessary for safe
and effective treatment, thus delaying recovery. There is also some concern that presenting
the patient with an overly cautious, gradual approach may send the message that they�re
an especially fragile person, thus reinforcing their feelings of hopelessness. The most recent version of the American Psychiatric
Association�s Diagnostic and Statistical Manual of Mental Disorders was released in
2013. The field trials for the DSM-5 found that
most individuals with CPTSD also could be diagnosed with PTSD. CPTSD was therefor rejected for inclusion,
and PTSD was instead broadened to consider more symptoms for diagnosis. Part of this has been due to a lack of CPTSD-specific
research, which itself is due to lack of inclusion in the DSM, a cycle that can be difficult
to break out of. There remains the possibility for future editions
of the DSM to portray trauma disorders as a spectrum, along which PTSD and CPTSD would
exist. In response to the claim that a phase-based
approach takes to long, the ISTSS experts point us back to the evidence I presented
earlier, showing the higher drop-out rate for patients of exposure therapy that was
not preceded by STAIR emotional skills-building. PTSD treatments on the whole have notoriously
poor success rates of reducing symptoms in general, so the entire field could benefit
from development of improved methods. Regarding the lack of distinction in the DSM-5,
the newly broadened symptom list for PTSD is now so broad that there are 636,120 ways
to have a disorder that qualifies for DSM-5 diagnosis. This actually makes it more difficult for
therapists to diagnose, let alone come up with an effective personalized treatment plan. The distinction between CPTSD and PTSD is
proposed for the 2017 edition of the World Health Organization�s International Classification
of Diseases, in accordance with several studies and the opinions of over 1700 experts worldwide. CPTSD is a more complex disorder requiring
a more extensive course of treatment than traditional PTSD. A phase-based approach tailored to the individual�s
symptoms is best, focusing on building emotional/relational skills before revisiting and desensitizing
traumatic memories. The goal of recovery from CPTSD is the restoration
of control and agency to the traumatized person. If you want to learn more, I highly recommend
visiting the National Center for PTSD on the VA�s website. They maintain up-to-date resources for providers
and patients alike.

51 thoughts on “Managing Complex Post-Traumatic Stress Disorder

  1. I'm 32y, finally understanding why I seemed to never overcome my emotional, reactive, abuseyf towards close relationships, complete paranoia dangerous that never happens but I'm always ready to react… I self medicat but at the pieces of failure and fallen each time worries in dangerous drug addiction to the edge… I have been through a life of my own personal education to my understanding of the environment… I felt ashamed and embarrassed to be responsible for my behavior when I remember the first years of my Life. IT'S funny when I relive past experience and recall my strongest emotion. It would be anything but petty for my situation..
    I was trying to win both my God like scared to be responsible for any trigger of verbal, vilonces, Fighting with no limits to be fully sense of my Life in danger… the worries are my physical harm I experiences were never ending once they both crossed the line in physically hitting me billing, no problem in keeping me in mental stress and fear… I could expect my mother give me special reinforced explanation towards her hitting me, verbally, fachal-budy-vilonte in my answering her at her excuses in her treating me in this manner… I was completely at her Mercy in worshipping her never questioning her ways in all aspects. It was extremely hard going into Foster for our protection, I was the oldest at 4y, my sister 2y, baby brother 1y. I think of my Biological Mother never stopped in abuseyf treatment. in my teenage years visiting her…. my sister was saved and my little brother also… throw years growing up and reinforcing myself and gaining experience from all aspects of dealing with vilonces at school, in the streets, grouphome and juvenile detention. never felt sorry for myself in experiencing hard situations. that were a challenge to better myself in dealing in the next occasion… I quickly realized how to avoid derct reaction but choosing to hold out for better outcome.this happens in complete natural reflect. I will leave a dangerous situation very first before my phycopath half is in complete control in a killing loss…. it's hard to make him stop each time. I prefer no longer using this tool for my personal goals in any aspects… the worst part of my own personal growth in understanding my own skills. I have done things that are bad and criminal… in outer consciousness needing to satisfy my basic needs… I don't have laws that fits in my own personal circumstances of being able to respect the laws of normally in the main that we take for granted….

  2. could watching ur father hold ur mother at gun point or hearing his threats of harm. then father abandoning you for years then at age of 13 to 18 being abused by boyfriend having baby at 15 ….keeps going…… is this trauma

  3. TY for posting. I've added this to my playlist for CPTSD and PTSD. I have a question. It's kind of been shown that the "what doesn't kill us makes us stronger" adage isn't correct–quite the opposite sometimes. So what can I substitute for a narrative when having flashbacks about the abuse?

  4. I was beaten by my mother with shoes, belts wooden spoons and other items because I am transgendered. I was bullied at school and then beaten at home because my clothes were dirty. My grandmother told my mom that hitting me would stop me from being who I was.  Now I am forced to care for her because I cant work, sop that only home I have is living in the same house where the abuse took place.

  5. Excited to see that the first step to recovery is what I need the most. I have emotional regulation problems and I would love to have control of them. Not just for myself, but the ones I love.

    I just had the realization a few days ago that I don't just have PTSD, I do have complex PTSD. My life has been filled with trauma. From sexual abuse/rape, child abuse, severe violent bullying, and 8.5 years of domestic violence, 2 traumatic car accidents where I blacked out just for the portion of impact–0 memory, and several other acts of violence as I lived in a poverty neighborhood growing up.

    I believe my triggers made the violence worse on me in the domestic violence. For example, I was crying my head off in the kitchen after a verbal attack. It was so severe that I started panicking and began hypervebtalating. He came into kitchen, which I thought was for a hug, and slapped me across the face and told me to knock it off. This only made it worse, of course.

    I can't seem to find answers to compounded adult trauma to childhood trauma. Does it make the complex PTSD worse? Can a person have complex PTSD and regular PTSD? Can trauma cause mental disorders (outside of PTSD)?

    None of my problems seem to lie outside the realm of complex PTSD. I also feel I might of resolved some problems by working on myself on my own for several years. I'm hoping to finally heal and become a new person after a life a trauma.

    I wouldn't wish a life of survival on anyone. It's sad to know so many have lived it.

  6. Shit…I have CPTSD from a mentally and physically abusive childhood. I was also a passenger in a bad car accident a long time ago and a few years after that badly broke my leg. I don't cope well with things based off of how I trained myself to do so as a child. I avoid relationships and it really has hurt me to this point in life. I have all this chronic pain and injury shit too. I just feel totally hopeless and like I'll just be alone, get old and die.

  7. hypothetical speculation; but could PTSD be misdiagnosed if including Somatoform disorders and PNES Psychogenic non-epileptic seizures. Thanks

  8. You should specify that this video is for mental health professionals. It's way too academic and loaded with abbreviations and clinical jargon to help anyone who is a victim looking for information.

  9. Like the comment about making a plan, help client realize how this is work to be done together, It requires a collaboration and empathize the need for an investment in their healing process. None of this is quick fix which is constant in this fast paced society.

  10. "Deterioration of emotional and relational skills?" I disagree. The previous "skills" of trusting a narcissist, sociopath, or other abuser is what allowed the unsuspecting person to be abused in the first place. It is completely NORMAL not to trust other people. Everyone else puts themselves first, with rare exceptions. TRUST YOURSELF. You alone know what is best for you, and it is better to be alone than to accept bad company. Get a dog if you want unconditional love.

  11. I found this video to be very enlightening and if you had specified it for mental health professionals I may not have clicked on it and would have missed out. So, thank you. I have been trying to verbalize a short bio of my hx which would support the position that unresolved trauma sustained in early development skews a person's perception of reality and creates patterns of maladaptive learned behavior combined with the inability to foster healthy boundaries actually grooming an individual for future abuse and trauma. This cycle of cause and effect is the very definition of Complex post traumatic stress Disorder and warrants it's own DSM category in my opinion. I'm amazed at the power of denial and dissociation. It truly is the matrix.

  12. Did you hear the story about the lady who was so undiagnosed and she was suicidal for about 50 years?!! I know it’s. ludicrous but it is me. i swear.

  13. I have C-P.T.S.D I'M AT BJC BEHAVIORAL HEALTH NOW…10-9-2018..♡♡♡♡♡☆☆☆♡♡♡☆☆♡♡♡♡XBOX

  14. Thank you for raising awareness of CPTSD. However, the above described approach remains predominantly cognitively based and therefore misses entirely several critcal areas that treatment of CPTSD requires. For example, the layers of unaddressed trauma often result in patients having little to no capacity for self-preservation. They frequently engage in behaviors that are dangerous, for example. Their ability or interest in sitting in an hour or two of therapy a week with the above framework and it being impactful would be rare. The impact of trauma -including the trauma of early emotional neglect –on all the senses warrants a holistic approach which would include a multi-sensorial, multi-modality approach (ie restorative yoga, art therapy, music therapy, equine assisted, EMDR , aramatherapy etc) — all working to integrate the mind and the body. The realization that these traumatic experiences impacted all sensorial pathways –and therefore an effective treatment approach would include addressing as many of those pathways as possible too. Please consider "The Body Keeps Score" by Bessel Van der Kolk, as a start to understanding why multisensorial treatment is the better approach.

  15. I am an avid #MentalHealthAwareness advocate and performer, and I love this so much. I travel the country trying to bring that awareness on stages, in classrooms, hospitals, and on my YouTube channel, so I get excited when I see other advocates. 💙❤

  16. Resourcing helped me out. Go back, if you can, to moments when you were fine. And discover you talents you have. Take them serious, even as Tiny They May seem and find a connection in the world outside. Then you encounter people with the same mindset but who are advanced in experience and you can learn from them. After a while this soul food starts to work : the good, the light becomes larger and the darkness smaller. Yes, the darkness won't Go away but you can transform it in a space of soft intimacy, even when you are alone. A simple candlelight Will do, a song, a smile, a dance … I wish you well 💟.

  17. I agree with Adventures in the Free World. You need to specify that this video is for clinicians NOT the average Joe Blow dealing with CPTSD. I was into 5 minutes of this before I realized I was totally tuning it out because I cannot process all the jargon…not helpful to me at all!!!

    ☆☆XOXO , DJ. DEBUSA♡♡2019

  19. First of all you have to except the fact you have a right to autonomy it’s your right as a human being. The truth kills us everything I was had to die because it was a regurgitation of someone else’s beliefs. In a massacre there is no good place to stand. The question is then how did you get there.
    The beauty of practice is that it transforms us so that we outgrow our original intentions and keep growing our motivations for practicing evolve as we mature. Ken Wilber
    Who looks outside, dreams; who looks inside, awakes.

  20. I've quit therapy every time I get close to examining the abuse I experienced while in a rehab facility as a teen. It's a year of my life that I know affects me every day but I can't make myself relive it. Not even to relate it to my therapist. I can talk about some of it but as soon as the feelings come back, I stop.

  21. It’s a bit of a cookie cutter video. There are some good points but it is way more complex than that. I know it was with me. Hence the complex

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