Treatment & Recovery 

If you exit a life of avoidance, dissociation, and numbing, it can feel like you are tiptoeing through a minefield of shame, fear, and anger. But you can make it out.

Instead of feeling powerless and perpetually victimized, you can find a new voice.

Sections:

• Recovering: 3 Key Stages
• Therapy Methods for CPTSD
• Positive Psychology & Resilience
• Prognosis

CPTSD Workbook, Arielle Schwartz PhD  /  CPTSD Treatment Manual  /  CPTSD: From Surviving to Thriving, Pete Walker

Recovering from Complex PTSD:
3 Key Stages of Long-Term Healing

Complex post-traumatic stress disorder, or CPTSD, doesn't spring up overnight. That means that recovering from complex PTSD requires commitment. Although emotional and physical scars probably make up a significant part of your history, there are solutions available for CPTSD recovery.

 STAGE 1: 
Create Safety & Stabilization

One of the key issues with C-PTSD is your need and craving for security. The first step in recovering from complex PTSD is the safety and stabilization phase. This includes both physical safety and emotional safety.

You can't even begin to recover from CPTSD unless you feel protected. A good trauma therapist will help you develop a deep felt sense of calm stability. You'll also learn skills that support that. For a significant period, a sense of safety was not present in your life. So it's very likely that your nervous system has an overactive habit of of being in fight, flight or freeze responses.

One of the hallmarks of trauma is that it leaves your nervous system chronically dysregulated. And if you suffer from CPTSD, then relationships are triggers.

Because therapy involves relating to another person, it's usually a trigger too. But, when you learn how to help your body feel and recognize safety, you can then learn how to have your needs met. Over time, you can begin to increasingly feel steady and support yourself.

Physical, mental, and emotional support are vital for all of us. Yes, we all need food, water, shelter, etc. But we also need to know that we won't be hurt or punished for expressing thoughts and feelings. At any other step in the stages of healing you might need to come back to safety and stabilization.

 STAGE 2: 

Practice Remembrance & Mourning

Skipping this stage of trauma therapy is something important that interferes with recovering from Complex PTSD. Many trauma survivors never recover because they don't do this stage of the work. This stage involves the resolution, or reconsolidation of old memories. Without this work, the brain can't move forward. 

Many survivors only have one coping tool; avoidance. And it's this very avoidance that keeps the trauma symptoms from resolving. Avoidance can be an excellent short term coping mechanism, but over the long run, it's what keeps the pain, fear, anger and shame swirling within our bodies and minds. Many wrongly believe that the only way to move forward is by not thinking about or not feeling what happened. 

What these people don't know is that a good trauma therapist can gently guide them through this stage and make sure that the process of remembering is not overwhelming. In fact, the key to successful trauma therapy is reprocessing and reconsolidating old memories in a comfortable enough way. 

The step of remembering and mourning the trauma is essential for recovering from complex PTSD. In this second step of the Complex PTSD recovery stages, you are actively engaged in trauma recovery work.

This is the heart of what's considered trauma therapy in that you are meeting with a therapist and working through what happened. There are several options available to do this safely and productively. For example:

• Eye Movement Desensitization and Reprocessing (EMDR)
• Neurofeedback Therapy
• Trauma processing therapies 

The mourning aspect is much like mourning a loved one you have lost. You are mourning all the things you have lost due to your trauma. It's the process of fully mourning that past which lets you come fully into the present.

Also, do keep in mind that if you are starting to feel unsafe, then it's time to revisit the safety and stabilization step. Once you are in a better place, you can continue with remembrance and mourning.

 STAGE 3: 

Recovering from Complex PTSD with Reconnection & Integration

With reconnection and integration, you can establish safety and stabilization as well as practice remembrance and mourning. Essentially, it's time to look ahead as you consider who you are without the cloud of trauma hanging overhead. In a way, this process is all about redefining and rediscovering who you are.

Learning to turn toward other people for closeness and pleasure is an important, and daunting step for many trauma survivors. So many trauma survivors find emotional and sexual intimacy to be overwhelmingly complicated. That leads them to practicing avoidance as as a way to feel stable and safe.

If you exit a life of avoidance, dissociation and numbing, it can feel like you are tiptoeing through a minefield of shame, fear and anger. But you can make it out.

Instead of feeling powerless and perpetually victimized, you can find a new voice. Oftentimes C-PTSD gives rise to a sense of purpose through service to others. Giving back helps any kind of recovery work. In the end, this step is all about forward-thinking, not dwelling on the past any longer.

Seek Therapy to Support Recovering from C-PTSD

The field of trauma treatment has come far. We have learned a lot about how trauma impacts the brain, the nervous system. And we've learned how to help people along the path of recovering from Complex PTSD. These stages of healing CPTSD require the assistance of a trained complex PTSD therapist who understands trauma and its after-effects.

A good therapist does more than just analyze what happened to you. They also walk with you through the recovery journey, allowing you the space to become safe and whole once again. A therapist empowers you to look back on those terrible moments, with less fear and shame and a greater sense of purpose and forward movement. 

Perhaps you endured complex PTSD symptoms for years. Recovering from Complex PTSD takes time but you needn't suffer aimlessly or alone. The intention of C-PTSD recovery is not to draw out the process. Rather, it is to intentionally engage in the stages of healing so that you can take back your life.
 

Coping with Symptoms

Treatments for complex PTSD can take time, so it is important to find ways to manage and cope with the symptoms of the condition. Some strategies that may help you manage your recovery:

• Find support
  Like PTSD, complex PTSD often leads people to withdraw from friends and family. However, having a strong social support network is important for mental well-being. When you are feeling overwhelmed, angry, anxious, or fearful, reach out to a trusted friend or family member.
   
• Practice mindfulness
  Complex PTSD can lead to feelings of stress, anxiety, and depression. Mindfulness is a strategy that can help you become more aware of what you are feeling in the moment and combat feelings of distress. This practice involves learning ways to focus on the present moment.
   
• Write down your thoughts
  Research has found that writing in a journal can be helpful in managing PTSD symptoms and decreases symptoms of flashbacks, intrusive thoughts, and nightmares.13 In terms of treatment, a journal can also be a great way to track symptoms that you can later discuss with your therapist.
   
• Support groups and self-help books can also be helpful
  when dealing with complex PTSD. Helpful book titles include "The Body Keeps Score" by Bessel van der Kolk, MD, and "Complex PTSD: From Surviving to Thriving" by Pete Walker.

Therapy Methods for CPTSD

There are various therapeutic approaches known to treat complex PTSD. There's no single therapy method that works best for healing C-PTSD. Therapists generally use a combination of psychotherapies that we will explore here, including CBT, DBT, EMDR therapy, somatic (body-centered) psychotherapy, and mindfulness—all administered within the context of a trusting relationship.

C-PTSD is relational trauma; in other words, it is harm caused by one person to another. Therefore, therapeutic interventions are most successful when you have a reliable relationship with your therapist.

The topic of C-PTSD can bring up vulnerable emotions. If anything starts to feel too painful or uncomfortable, you can always put this book down. Listen to your intuition about how to pace yourself. There is nothing wrong with slowing the process down if you need more time to integrate new information.

Cognitive Behavioral Therapy

Originally developed by Dr. Aaron Beck in the 1960s, cognitive behavioral therapy (CBT) is still considered one of the most effective types of counseling for PTSD.*

In general, CBT helps you recognize the relationships between your thoughts, emotions, and behaviors. CBT assists in replacing distorted or distressing thoughts with more accurate and positive beliefs.

Two forms of CBT are most frequently applied to the treatment of PTSD: exposure therapy and cognitive processing therapy.
  

EXPOSURE THERAPY

Exposure therapy involves desensitizing yourself to the trauma by repeatedly talking about your traumatic memories until you feel less overwhelmed by them.

While initially it may feel uncomfortable to talk about the trauma, turning toward your past can be empowering. This method also employs relaxation methods and breathing exercises to calm down your mind and body.

There has been concern that this method can sometimes be too direct, and as a result, feel re-traumatizing to some.

It is important to trust your instincts when choosing the right therapy for you, and to speak up when a method feels uncomfortable or ineffective, so your therapist is aware and can help or change the process.
 

COGNITIVE PROCESSING THERAPY

Cognitive processing therapy (CPT) reduces the power of fearful memories by activating a fearful memory while simultaneously introducing new information that is incompatible with beliefs surrounding the memory.

For example, a belief that the trauma was your own fault is challenged when you recognize that you were just a child; you couldn't have done anything wrong.

CPT educates about PTSD symptoms; helps develop awareness of your thoughts and feelings; guides you to incorporate new, more positive beliefs; and encourages practicing new skills that propel insights into actions.

All forms of CBT explore any inaccurate beliefs you may hold. Common negative beliefs include:

• I am unlovable
• I am unimportant
• I cannot trust anyone
• I am unworthy
• I do not deserve to exist
• I don't belong
• I am helpless or powerless
• I did something wrong

A key component of treatment is to replace negative self-statements with positive beliefs. Some examples:

• I am lovable
• I am important
• I am worthy
• I survived
• I belong
• I am strong
• It is safe to love and trust now
• I can learn from my past
   
  

Dialectical Behavior Therapy

Dialectical behavior therapy (DBT) was originally developed in the 1980s as a specific type of cognitive behavioral therapy for the treatment of borderline personality disorder. More recently, DBT has been applied to treat other disorders, and has been found particularly beneficial for C-PTSD.

This therapy is founded on principles of Zen Buddhist philosophy and contemplative practices.

The primary dialectic within DBT is the polarity between acceptance and change, which recognizes that radical acceptance of who you are is a necessary condition for change and growth.

Typically, DBT therapy involves individual and/or group therapy sessions that focus on the development of mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness.
 

MINDFULNESS

Within the context of DBT, mindfulness skills focus on developing your capacity to observe your own mind while cultivating acceptance. Acceptance helps you recognize that uncomfortable experiences do not necessitate escape tactics or reactivity.
 

DBT offers the concept of "Wise Mind," which represents the optimal balance of your "reasonable mind" (or thinking) with your "emotional mind" (or feeling)-an integration of logic and intuition that can help you feel calm and centered.
 

EMOTION REGULATION

DBT emotion regulation skills are based in a context of mindfulness and acceptance.

The goal with this approach is not to get rid of your emotions; rather, it is to reduce suffering related to ineffective reactions to your emotions.

An example would be lashing out at a supportive partner in fear or anger when perhaps they've done nothing wrong-this reaction causes additional suffering for you and your partner.

DBT distinguishes that difficult feelings are not destructive or the result of a bad attitude. These emotions are simply meant to be felt, and this is where the mindfulness and acceptance come in.

Emotion regulation helps you learn to distinguish between feelings and "action urges," which encourages you to reflect on your thoughts and emotions before jumping to reactions or behaviors.
 

DISTRESS TOLERANCE

Pain and distress are a basic part of life, and sadly, they cannot be entirely avoided. The goal of distress tolerance in DBT is to be able to handle painful emotions skillfully.

Sometimes skillful action involves acceptance-welcoming reality as it is, without needing to resist or change it. Other times, skillful action requires change; such as recognizing when it is important to leave an unhealthy situation.
 

INTERPERSONAL EFFECTIVENESS

The DBT skills taught for interpersonal effectiveness emphasize assertiveness, boundaries, and coping with conflict.

Assertiveness focuses on developing your capacity to ask for what you need, even though you may be told no or risk feeling rejected.  

Self-assertion involves building self-respect and cultivating a sense of your own worthiness.

Skills for interpersonal effectiveness include learning to address conflicts gently, such as by refraining from put-downs or name-calling, respecting yourself and others, ensuring that you are behaving fairly, apologizing when you have done something wrong, and being truthful. These basic skills can be powerful catalysts for inner strength and positive self-esteem.
 

EMDR Therapy

Eye movement desensitization and reprocessing (EMDR) therapy, developed by Dr. Francine Shapiro, is a comprehensive approach to therapy that integrates elements of several different therapies.

EMDR therapy is structured to treat PTSD by identifying triggering memories, emotions, beliefs, and sensations. 

It relies on the concept that with sufficient support, you'll have the capacity to process and digest traumatic events. As a result, you'll be able to let go of self-critical beliefs and painful emotions.
 

EIGHT PHASE TREATMENT MODEL

EMDR therapy uses a treatment model split into eight phases.

The initial phases prepare you to process the trauma by identifying traumatic memories and the negative beliefs associated with them. You then review your history by taking an in-depth look at your symptoms.

The desensitization phase incorporates the use of a dual awareness state, in which you are asked to remain aware of your present moment experience while simultaneously recalling memories of the traumatic event.

Dual attention is amplified using stimulation in the form of eye movements, buzzers, or tones that alternate between the left and right side of your body. Later phases of EMDR therapy focus on strengthening positive beliefs.
 

RESOURCES FOR EMDR THERAPY-BASED TRAUMA RECOVERY

The preparatory phase of EMDR therapy involves building resources to be able to attend to the frightening and sometimes overwhelming trauma-related memories.

These resources include:

• Safe place:
  Here you identify a place that is either real or imaginary, and where you feel safe, allowing your body and mind to have a reference place that supports relaxation and ease.
   

• Containment:
  Here you develop an imagined container: a place or item that is big and strong enough to hold painful thoughts, feelings, and memories. The container is meant to be used temporarily during times when you are not actively engaged in processing your traumatic memories.
    

• Allies:
  Here you identify imagined or real beings that you associate with nurturance, protection, and wisdom. Allies can be people, animals, or spiritual or religious figures. 
  

EMDR therapy not only processes past events, but also identifies the necessary positive beliefs to facilitate greater choice in the present. For example, once an individual no longer holds the misconception that they are unlovable, they can begin to develop and integrate a new positive belief that they are worthy of being loved.
 

Somatic Psychotherapy

Somatic modalities are therapy approaches that focus on the body rather than the mind. Therapies such as Somatic Experiencing® (developed by Peter Levine) and Sensorimotor Psychotherapy (developed by Pat Ogden) engage body awareness to release the psychological and physiological impact of traumatic events.

Reasoning and logic alone are seldom sufficient to treat trauma.

When exposed to frightening experiences, your breath quickens and tension builds throughout your body. To process trauma, you need to breathe and move.
 
However, our culture tends toward stillness in the face of trauma. When body awareness is not included in trauma processing, you inhibit your ability to work with your innate healing capacities.

Somatic awareness, or an awareness of your body's sensations, can teach you how to gauge your body's feedback so you can recognize when your traumatic past no longer holds power over you.
 

SOMATIC AWARENESS

Somatic psychotherapists invite clients to be curious about body sensations.

Mindfully staying connected to the body in the midst of powerful emotions or sensations helps you regulate and respond more effectively to emotional intensity. Simply bringing awareness to physical tension and breath patterns begins the process of healing.
 

SEQUENCING

Sequencing refers to the movement of tension out from the core of your body through the extremities. It can be involuntary, but can also be facilitated through mindful movements such as following an urge to move something.

Sequencing is helpful, as it allows the releasing of tension patterns related to freeze, fight, or flight responses in the body. Sometimes sequencing occurs as a visible trembling in the arms or legs. Other times it is experienced as a movement pattern.
 

GROUNDING*

Grounding refers to your ability to sense your body, feel your feet on the earth. and as a result, calm your nervous system. This concept sits at the heart of somatic psychotherapies.

Grounding is a key resource for trauma and emotional overwhelm. Your senses (hearing, seeing, smelling, tasting, touching) are tols tr anchoring yourself in the present moment.

Treating complex PTSD often involves "parts work" as a way to understand avoidance, intrusive, and depressive symptoms.

Often referred to as ego state therapy, this approach to healing recognizes that you develop different parts of yourself to hold unwanted or unacceptable feelings and memories.

Ego states are often parts that reflect younger developmental phases of your life related to traumatic memories. This is why you might sometimes feel like a wounded child or a rebellious teenager.

Parts can also represent an internalization from your family of origin. For instance, you can think of an inner critic as an internalization of a critical parent from childhood.
 

Complementary & Alternative Medicine

Complementary and alternative medicine (CAM) interventions, such as relaxation, mindfulness, and yoga, have been integrated into many mental health centers and hospitals as supportive treatment for PTSD.

They work by regulating your autonomic nervous system (ANS). Recall that your ANS consists of sympathetic and parasympathetic nervous system states.

Optimally, you can reclaim balance in your body and mind by finding ways to calm down when anxious and feel nurtured by your capacity to rest and feel nourished.

However, with C-PTSD it is common to react to situations in ways that can be irrational, or not based in reality. In such moments, feelings of worry, frustration, or hopelessness can intertere with your ability to take care of yourself and your relationships in healthy ways.

A common trajectory of how feelings of abandon-ment, anxiety, and exhaustion can take over when we don't have the tools to remain calm and mindful. 

Let's take a closer look at the science behind this downward spiral: 

The vagus nerve plays a central role in ANS regulation because it connects your brain to your digestive system, heart, lungs, throat, and facial muscles.
 

Dr. Stephen Porges introduced polyvagal theory, which proposes your nervous system reflects a developmental progression with three evolutionary stages:
 

• When you experience a stressful event, your ANS responds with sympathetic nervous system mobilization into the fight-or-flight response. This process aims to protect you and help you reestablish safety.
   

• If you can't resolve the stressful situation or are facing a life-threatening event, you will resort to an earlier set of evolutionary mechanisms maintained by the dorsal vagal complex (DVC). This parasympathetic branch of your vagus nerve puts an abrupt, unrefined brake on your sympathetic nervous system by promoting immobilizing defensive actions such as fatigue, depression, or dissociation-consider concepts like fainting or feigning death.
   

• In order to regulate your ANS, you need to engage the most recently evolved parasympathetic branch of the vagus nerve called the ventral vagal complex
   

(VVC), or alternatively, the social nervous system. This branch functions as a highly refined brake on sympathetic activation, and has a calming and soothing effect.

Importantly, both the DVC and VVC have parasympathetic actions that exert inhibition on the sympathetic nervous system.

The DVC inhibits it in a negative way (dissociation, helplessness, and despair), which can have serious repercussions on mental and physical health. 

Conversely, the VVC is associated with increases in health and emotional well-being, as it allows you to rest, digest, and relax into feelings of safety and connection. 

Your social nervous system is strengthened by repeated practice. Ideally, this practice occurred in early childhood with a loving and consistent caregiver. However, with situations of early neglect or abuse, this was not the case.

It is essential to develop your social nervous system in other ways. *This can occur within healthy relationships in adulthood such as with a psychotherapist.

CAM therapies such as relaxation, mindfulness practices, tai chi, gigong, and yoga all strengthen the social nervous system.
 

RELAXATION TECHNIQUES

Relaxation techniques are beneficial for the healing of C-PTSD. Some of the most common and well-researched techniques include progressive muscle relaxation (PMR), visualization, and diaphragmatic breathing. In each of these practices, you focus on calming down your body.

In PMR, you sequentially tense and relax various muscle groups (e.g., arms, legs, torso, neck) throughout your entire body. Visualization involves recalling memories of times when you felt relaxed, and allowing your body to respond accordingly. Slow and rhythmic diaphragmatic breathing, or "belly breathing," helps calm you down if your body is in a fight-or-flight response.
 

MINDFULNESS

Mindfulness in psychotherapy involves engaging in practices that encourage awareness of the present moment, a mind-set of nonjudgment, focus on bodily felt senses, relaxation techniques, and awareness of breathing patterns.

Mindfulness has many proven benefits for mental and physical health. Two well-known programs include mindfulness-based stress reduction (MBSR), developed by Dr. Jon Kabat-Zinn, to manage stress and anxiety, and mindfulness-based cognitive therapy (MBCT), developed by Dr. Zindel Segal and colleagues, which applies mindfulness to treat major depressive disorder.

Research on the effectiveness of mindfulness practices reveals improvements in anxiety, depression, sleep disorders, asthma, chronic pain, fibromyalgia, heart disease, gastrointestinal diseases, and diabetes.
 

OTHER TREATMENTS FOR C-PTSD

Many other therapeutic modalities offer beneficial perspectives for the healing of C-PTSD. While not all can be discussed in depth, a few remain noteworthy:

POSITIVE PSYCHOLOGY & RESILIENCE

 
Positive psychology focuses on strengths and capabilities rather than diagnoses or deficits. In treating PTSD, applying the science of positive psychology recognizes that you have the ability to be resilient despite your traumatic history. You can adapt well and even be strengthened by adversity. For example, many people who have traumatic histories report having a strengthened commitment to happiness and a life path with purpose and determination.

Resilience is not a trait that you either have or do not have. It is a set of strategies that can be learned and practiced by anyone. Strategies include:

• Cultivating a growth mindset, in which you believe you can grow through both positive and negative life events

• Staying connected to your community rather than isolating yourself

• Successfully working through difficult emotions 

• Believing that you have the capacity to shape the course of your life now 

• Supporting your physical health through movement and exercise 

• Expressing yourself through journaling and creativity Resilience is a process that is best served when you actively participate in supporting your physical, mental, emotional, social, and spiritual health each and every day.
  

You can build your resilience by engaging in small actions such as calling a friend, writing for five minutes in your journal, or taking a walk around the block. While each one of these steps might seem small, collectively they can help you feel strong, relaxed, capable, and more connected to others in the world.

The Complex PTSD Workbook, by Arielle Schwartz PhD offers practices that are aimed at developing your resilience and strengthening your positive mind-set.

 Prognosis 

What is the prognosis (outlook) for CPTSD? 

For many people, CPTSD is a lifelong condition. The good news is that psychotherapy and medication can help manage your symptoms.

Recovering from complex PTSD takes time. The condition may pose lifelong challenges. However, prolonged trauma-focused treatment can help significantly decrease symptoms. 

A doctor will need to look at the specific person's history of trauma to develop the best course of treatment. Complex PTSD may require longer treatment than traditional PTSD and a larger variety of interventions, particularly those that focus on issues with self-organization.

One goal of treatment is to attempt to develop or recapture feelings of trust in others and the world. This can take time, but participating in healthy relationships is a positive step.

With the right therapy, medication, and lifestyle changes, people can manage or reduce their symptoms and improve their overall wellness. 

It may be very difficult to seek help after chronic trauma. Know that treatment for complex PTSD is important, and with time, treatment can help you get better.

Aside from seeking treatment for acute stress disorder, things you can do to help yourself include:

• Engaging in mild exercise to help reduce stress and boost your mood.
   
• Setting realistic goals for yourself.
   
• Spending time with people you trust and educating them about your experience and things that may trigger symptoms.
   
• Identifying and seeking out comforting situations and places.
   
• Attending a support group for people who have experienced trauma.
   
• Being patient and kind to yourself. You should expect your symptoms to improve gradually, not immediately.
   

If you're having thoughts of harming yourself or suicide, go to the nearest emergency room or call the Suicide and Crisis Lifeline.

SOURCES:

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COMPLEX PTSD - SHAME - AVOIDANCE - HYPERVIGILANCE - DYSREGULATION - INTERPERSONAL DIFFICULTIES - DISSOCIATION - IMPULSIVITY - OBSESSIVE THOUGHTS - DEPRESSION - TRIGGERS - PHYSICAL - PERSONAL EXAMPLES