Exploring Care Approaches for Complex Trauma

As a therapist, you may be familiar with Posttraumatic Stress Disorder (PTSD). It can be caused by a singular event that is — or is perceived to be — life threatening, and while it is often associated with the experience of military service members, it can be caused by a dog bite, a car accident, or physical or sexual assault, among many other experiences.  

What you may have less familiarity with is complex PTSD (c-PTSD), or complex trauma. While much of the diagnostic criteria is similar to PTSD, it is deeply relational and often occurs from chronic incidents of emotional, behavioral, physical, or sexual safety being placed in jeopardy — like a rug being repeatedly ripped out from underneath someone.

While much of complex trauma can be attributed to family of origin dynamics or other interpersonal relationships, it is also important to identify broader systemic triggers. Many BIPOC folks will seek treatment for complex trauma as a result of systemic racism, alienation, dehumanization, or immigrating into a system with life-altering hurdles. In addition, neurodivergent individuals often identify deep trauma after lifelong invalidation from a culture built for neurotypical brains.

Treating complex trauma can feel overwhelming while you’re developing your trauma-informed skills, and, just as we tell our clients, it gets better! Here are a few things to keep in mind when caring for clients with complex trauma:

Start from the beginning

The beginning stage of treatment often involves identifying which threads in the fabric of someone’s emotional foundation were created by fear, people-pleasing to avoid abuse, and survival mode. 

This can feel overwhelming for clients and requires a lot of normalizing: they are expanding their knowledge of how their experiences have shaped their lives in order to replace the threads with healthier foundational coping and ways of being. Many will begin treatment with knowledge of a few of those threads, and will slowly build awareness of what else can be rebuilt.

Look for common birthplaces of complex trauma

It is important to look for situations that often create complex trauma. These can include having a family member with undiagnosed, untreated, or treatment-resistant mental health disorders; intimate partner violence; institutionalized violence; or sexual trauma.

Complex trauma can manifest itself through shame, difficulty expressing vulnerability, poor boundary-setting, codependency, unstable sense of self, low self-worth, dissociation, remaining in or repeatedly seeking out unhealthy interpersonal relationships, mood lability, self-injurious behavior, or suicidal ideation. Many individuals with Borderline Personality Disorder struggle with complex trauma, though the reverse isn’t always true.

Take a strength-based approach

As awareness of symptoms builds, complex trauma clients can feel they have a long list of things to perceive as personal failures, so taking a strength-based approach is key. Asking individuals to identify what strengths led them to survive their situation can be inherently healing — was it strength of will? A person who demonstrated that healthier ways of being exist? Was it dissociation to survive abuse?  

Dissociation is a common experience of complex trauma, and this again can be reframed as a strength. In the moment, it was their brain’s way of surviving a dangerous situation, and that should be applauded, as it kept them alive.

Understand the thriving self and the surviving self

When complex trauma clients come into treatment, there is often an internal battle occurring between their “thriving self” and their “surviving self” that must be illuminated. If you’re familiar with Internal Family Systems, you are likely nodding your head!

The “surviving self” is the part that stayed alive long enough to allow the “thriving self” to work toward a better life. Perhaps their “surviving self” engages in habitual dissociation, while their “thriving self” identifies this as a roadblock to being fully present, and therefore a mechanism of self-sabotage. This internal battle depletes energy and motivation and requires empathetic communication between the two parts to heal the divide.

When the “surviving self” is engaging in self-injurious behaviors, or is posing a danger to themselves or others, it is important to work toward safety before moving forward. Teaching coping skills to manage safety concerns will benefit both short-term and long-term needs of all selves involved. While clients may perceive skill-building as a roadblock to “processing trauma,” clinicians can provide this reframe: foundational threads must be built from healthy coping in order for everything built on top of it to be stable.

Common homework assignments: 

These exercises can help clients work with complex trauma outside of the therapy room.

• Writing letters between the surviving and thriving selves — like pen pals —to uncover their feelings toward one another and understand their individual perspectives
• Tracking triggers to deconstruct in sessions with questions like: What was the triggering event? How can I respond to it?  Which self was triggered and how did they handle it?  What is the difference between avoiding triggers and removing myself from unhealthy situations?
• Externalizing the surviving self as a wounded inner child, and practicing speaking to it through this lens (i.e “if you wouldn’t say this to a child, you shouldn’t be saying this to yourself,” and “just because someone spoke to you cruelly, doesn’t mean you need to carry on the tradition”)
• Practicing motivating through a positive instead of a negative. For example, instead of “If I don’t get this done, I am worthless and will never get better,” try saying, “I will feel so much relief if I get this done.”

Complex trauma becomes simpler to treat when you view your clients for who they are: humans who have experienced great pain and have found ways to survive that are no longer serving them. 

The importance of modeling as a clinician

Power imbalances in the therapy room are heightened with complex trauma clients, as many have experienced pain by someone in a position of power or authority. It is important to model accountability, vulnerability, and healthy responses to conflict, rejection, and mistakes. Modeling these traits can offer an example of healthy relationships they can seek outside the therapy room.  

As you improve your practice with complex trauma, seek consultation when you need it, give yourself the grace you give to others, and remember your most important lesson as a therapist that we all must learn: the more you take care of yourself, the greater the ripple effect to those in your presence.

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