Therapy activities and ideas
Summary
Understanding complex PTSD vs. PTSD treatment approaches is critical. PTSD responds to event-based therapies like EMDR and CPT, while C-PTSD requires attachment-focused treatment addressing developmental trauma and disturbances in self-organization.
Differential trauma treatment starts with knowing how to diagnose between C-PTSD and PTSD using tools like the CAPS-5, PCL-5, and ITQ, as each condition demands distinctly different therapeutic interventions.
The question of which stabilization techniques work best and when to address developmental trauma differs significantly: PTSD stabilization is relatively brief, while C-PTSD requires extended attachment-based work before any processing begins.
What are the best protocols for each condition? Event-based therapies excel for PTSD, while effective complex PTSD vs. PTSD treatment approaches recognize that C-PTSD demands phase-based, attachment-centered modalities and specialized techniques for handling emotional flashbacks.
In recent years on social media and in popular culture, people have been more casually throwing around the diagnosis post-traumatic stress disorder (PTSD), and, most recently, complex post-traumatic stress disorder (C-PTSD).
While most people don’t escape life without some kind of trauma, a diagnosis of PTSD or C-PTSD describes a condition with a very specific set of criteria.
So, what exactly is PTSD and C-PTSD and what are the complex PTSD vs. PTSD treatment approaches?
First, let’s explore the definitions. While PTSD was added to the third edition of the Diagnostic Statistical Manual of Mental Disorders (DSM-III) in 1980, C-PTSD was left out, with the argument being that it was too similar to PTSD to have its own diagnostic criteria.
Many in the psychotherapy field argue that there are flaws to the exclusion of C-PTSD as a diagnosis. However, in 2018, the World Health Organization (WHO) added C-PTSD as a diagnosis, with official implementation of the diagnosis in 2022.
What is PTSD?
PTSD is characterized and defined by the DSM-5-TR as “the development of characteristic symptoms following exposure to one or more traumatic events.”
PTSD occurs when a person has a maladaptive stress response that occurs for more than a month following an event and causes significant impairment and functioning in a person.
How is C-PTSD different?
The concept of C-PTSD was first introduced in the late 1980s by Judith Herman, M.D., who had observed something distinctly different from PTSD in those who had experienced ongoing and pervasive harm that fundamentally altered who they are.
The WHO defines C-PTSD as different from PTSD, saying, “The symptoms of complex PTSD are pervasive and enduring. The disorder differs from PTSD in that it includes the additional features of disturbances in self-organization (DSO).”
C-PTSD has three key areas that differ from PTSD related to disturbance of self: emotional dysregulation, negative self-concept, and disturbances in relationships.
In C-PTSD, it is common to see these disturbances play out as disruptions of attachment in relation to self and others.
When considering complex PTSD vs. PTSD treatment approaches, these differences in presentation demand different therapeutic interventions.
How does C-PTSD treatment differ from PTSD?
For those wondering “How does C-PTSD treatment differ from PTSD treatment?” the answer lies in understanding these core distinctions in symptom presentation and their implications for treatment.
When considering definitions, psychotherapist and professor of social work Kalie Wolfinger, LCSW, talks about the difference between post-traumatic stress disorder (PTSD) and complex post-traumatic stress disorder (C-PTSD), describing it with an analogy:
“PTSD is like having a rock thrown through a window in your home: sudden, violent, and damaging. It’s obvious what caused the break, and though serious, it can often be repaired once the danger has passed. C-PTSD is like living in a house where mold slowly creeps through the walls over many years. It starts subtly, a musty smell to a few headaches, but by the time the damage is recognized, it’s systemic. The foundation has been compromised, and remediation involves a deep, layered process that includes rebuilding trust in what should have been a safe environment.”
When we conceptualize the pervasiveness of trauma in this way, we have to think very intentionally about how to treat each condition uniquely.
This is the foundation of differential trauma treatment.
How to diagnose between C-PTSD and PTSD
Before any treatment of PTSD and C-PTSD occurs, it is important to screen appropriately for each, as utilizing modalities that are not specifically for PTSD (or other disorders) and C-PTSD can cause additional harm.
Knowing how to diagnose between C-PTSD and PTSD helps to accurately guide appropriate treatment selection.
For clinicians new to working with clients with PTSD, several good places to start are the Clinician-Administered PTSD Scale (CAPS-5) and the self-report Posttraumatic Stress Disorder Checklist (PCL-5). Additionally, the International Trauma Questionnaire (ITQ) screens for both PTSD and C-PTSD.
These screening tools will help a clinician assess for trauma, while the ITQ will look at the differences and similarities between each. Along with clinical assessment and history taking, this can lead to a diagnosis of PTSD or C-PTSD.
Stabilization in trauma work
Stabilization techniques (and the length of time for each) can look different for PTSD and C-PTSD, but most therapists agree that when working with anyone with trauma, stabilization is the first step as rapport and safety are being established.
Stabilization begins with helping a client feel grounded and connected to themselves and their body, the world around them, and eventually, to others.
Stabilization is deeply connected to nervous system regulation work (think box breathing, orienting to the room, titration in and out of big emotions, or noticing sensations in the physical body with a body scan and progressive muscle relaxation).
Stabilization can look like helping a client work through how they are eating, sleeping, and orienting to time and space as well as being OK and safe in their own body.
Working in the stabilization phase in PTSD can be relatively short, but with C-PTSD, it takes patience—and in many cases, it requires utilizing an attachment lens that looks at developmental trauma that occurred in childhood.
Managing emotional flashbacks in therapy
When working with trauma, emotional and physical flashbacks are common and can happen for clients with and without complex PTSD.
For those wondering how to handle emotional flashbacks, managing flashbacks with clients often looks like utilizing grounding techniques learned in the stabilization phase of work, and helping a client remember where they are in present time vs. where they were in the past.
For C-PTSD, this kind of stabilization can take years because the lack of safety is so pervasive.
For many clients, emotional and physical flashbacks can feel all-consuming, and it can feel as if they are dying or unable to move forward. The body may feel stuck, or clients may experience sensations that occurred during trauma.
Someone experiencing a flashback may not be able to articulate that they are not back in the moment of trauma or abuse.
In the book “The Body Keeps the Score” by Bessel van der Kolk, MD, he says, “We have learned that trauma is not just an event that took place sometime in the past; it is also the imprint left by that experience on mind, brain, and body. This imprint has ongoing consequences for how the human organism manages to survive in the present. Trauma results in a fundamental reorganization of the way the mind and brain manage perceptions. It changes not only how we think and what we think about, but also our very capacity to think.”
Clinicians working with trauma will often see Van Der Kolk’s observations play out when emotional flashbacks threaten the stability of someone who has experienced trauma.
This understanding shapes how to handle emotional flashbacks differently across complex PTSD vs. PTSD treatment approaches.
What are the best protocols for each condition? Modalities for processing trauma
Differential trauma treatment protocols vary significantly based on diagnosis.
So, what are the best protocols for each condition? Modalities that focus on working with clients with PTSD often utilize event-based therapies, such as looking at the specific thing that occurred and processing the harm of that event.
PTSD can often see positive results with eye movement desensitization and reprocessing (EMDR), cognitive processing therapy (CPT), prolonged exposure therapy, and somatic-based therapies that focus on the body’s response.
PTSD treatment can be relatively short (under a year) or can be long-term.
When looking at treating C-PTSD, event-based therapy can be damaging and exhausting for the client because the trauma often occurs over a period of time, with many events done by a “human with intention,” at the hands of an attachment figure or person who should have protected instead of harmed.
If a therapist is utilizing an event-based modality for PTSD, it can feel impossible to get through the many, many events that led to the client’s complex trauma. For a client with C-PTSD, reliving the things their body has gone through can be extremely disorienting, dysregulating, and disorganizing.
When working with clients with C-PTSD, attachment is everything.
C-PTSD treatment needs to be grounded in attachment work that helps a client reorganize their sense of self and the world. Modalities that are phase-based and focused on stabilization, regulation skills, and relational safety are essential.
Several modalities shown to have efficacy with C-PTSD include trauma-focused dialectical behavioral therapy (DBT), internal family systems (IFS), attachment-focused EMDR and somatic-based therapies (specifically for stabilization).
Because it is attachment and safety-based and focused on re-organizing how a client connects with themselves, others, and the world around them, C-PTSD treatment is almost always long term.
It cannot be stated enough: attachment is everything. Effective complex PTSD vs. PTSD treatment approaches require this fundamental understanding of attachment's central role in C-PTSD recovery.
In Stephanie Foo’s memoir “What My Bones Know: A Memoir of Healing from Complex Trauma
,” which details her life and finding her way to a diagnosis of PTSD and eventually C-PTSD, she writes: “Being healed isn’t about feeling nothing. Being healed is about feeling the appropriate emotions at the appropriate times and still being able to come back to yourself.”
PTSD and C-PTSD are different diagnoses and clinicians should screen for, assess, and treat them differently through appropriate differential trauma treatment approaches.
However, there is a fundamental truth in working with both: At the end of the day, engaging in healing any kind of trauma is about helping a person come back to themselves and helping them find their connection with themselves and others. And, when that connection happens, transformation happens.
Understanding and developing a full awareness of complex PTSD vs. PTSD treatment approaches takes time, training, and commitment to understanding how these conditions differ. Implementing differential trauma treatment effectively means honoring these differences while keeping connection and safety at the center of all therapeutic work.
Sources
Books and clinical resources
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.).
Chard, K. M., Monson, C. M., & Resick, P. A. (2016). Cognitive processing therapy for PTSD: A comprehensive manual. Guilford Press.
Courtois, C. A., & Ford, J. D. (Eds.). (2009). Treating complex traumatic stress disorders: An evidence-based guide. Guilford Press.
Fisher, J. (2017). Healing the fragmented selves of trauma survivors: Overcoming internal self-alienation. Routledge.
Foa, E. B., Hembree, E. A., & Rothbaum, B. O. (2007). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences. Oxford University Press.
Foo, S. (2021). What my bones know: A memoir of healing from complex trauma. Ballantine Books.
Herman, J. L. (1992). Trauma and recovery: The aftermath of violence—from domestic abuse to political terror. Basic Books.
Mosquera, D., & Gonzalez, A. (2014). EMDR therapy and complex PTSD: From attachment trauma to self-integration. CreateSpace Independent Publishing Platform.
Shapiro, F. (2018). Eye movement desensitization and reprocessing (EMDR) therapy: Basic principles, protocols, and procedures (3rd ed.). Guilford Press.
van der Hart, O., Nijenhuis, E. R. S., & Steele, K. (2006). The haunted self: Structural dissociation and the treatment of chronic traumatization. W. W. Norton & Company.
van der Kolk, B. (2014). The body keeps the score: Brain, mind, and body in the healing of trauma. Viking.
Assessment tools
Cloitre, M., Shevlin, M., Brewin, C. R., Bisson, J. I., Roberts, N. P., Maercker, A., Karatzias, T., & Hyland, P. (2018). The International Trauma Questionnaire: Development of a self-report measure of ICD-11 PTSD and complex PTSD. Acta Psychiatrica Scandinavica, 138(6), 536–546.
Weathers, F. W., Blake, D. D., Schnurr, P. P., Kaloupek, D. G., Marx, B. P., & Keane, T. M. (2013). The Clinician-Administered PTSD Scale for DSM-5 (CAPS-5). National Center for PTSD.
Weathers, F. W., Litz, B. T., Keane, T. M., Palmieri, P. A., Marx, B. P., & Schnurr, P. P. (2013). The PTSD Checklist for DSM-5 (PCL-5). National Center for PTSD.
Diagnostic criteria and professional resources
World Health Organization. (2019). International classification of diseases for mortality and morbidity statistics (11th Revision).
National Center for PTSD. (n.d.). PTSD: National Center for PTSD. U.S. Department of Veterans Affairs.
Herman, J. L. (2012). CPTSD is distinct from PTSD: Scientific and clinical implications. Psychiatric Times.
Interview and multimedia
OnBeing. (2015, October 15). Judith Herman — Trauma and recovery [Audio podcast episode].
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