Complex PTSD: Signs, Complex Trauma, EMDR and Trauma-Focused CBT Treatment

Surviving trauma can affect a person long after the traumatic experience itself has ended. Sometimes, the impact becomes more noticeable not during the crisis itself, but later when life begins to feel safer, more stable, or when things finally start to go well. This may happen when the mind and body no longer have to focus simply on safety and surviving.

For some people, trauma is linked with a single event. For others, the impact may come from repeated, prolonged or early experiences where it was not possible to feel safe, escape, be protected or have needs accepted or understood. When trauma has affected a person’s emotional world, relationships, sense of self and sense of safety, the term complex PTSD, or C-PTSD, may be relevant.

In brief: Complex PTSD, or C-PTSD, is a trauma-related difficulty that includes symptoms of PTSD, such as flashbacks, avoidance and feeling on red alert, alongside more persistent difficulties with emotional regulation, self-worth and relationships. EMDR and trauma focussed CBT are evidence-based trauma therapies that may help, but for complex PTSD they often need careful preparation, pacing and attention to safety, trust and stabilisation.

Some people who have lived through trauma may also have been given other diagnoses, including emotionally unstable personality disorder, sometimes called EUPD, or borderline personality disorder, sometimes called BPD. For some, a diagnosis can be useful because it gives them a way to search for information and read about other people’s experiences. For others, hearing the words “personality disorder” can feel painful, blaming or as if the problem is being located only inside the individual.

A trauma-informed approach asks a different question. Rather than starting with “What is wrong with you?”, it may be more helpful to ask, “What happened to you, how did you survive, and what is still affecting you now?”

One alternative descriptive term suggested in the clinical literature is trauma induced emotional regulation and interpersonal relational difficulties, or TIERI. This is not a formal diagnosis, but a trauma-informed descriptive phrase aims to describe the impact of trauma on emotions and relationships without implying that the person’s personality is “disordered”. Darongkamas and colleagues used the term TIERI in the work on training NHS staff to work more helpfully with people often given a diagnosis of BPD/EUPD. See their published paper here.

What is Complex PTSD?

Complex PTSD is a trauma-related difficulty. It includes the core symptoms of PTSD, but also involves broader effects on emotional regulation, self-worth and relationships.

People with PTSD or complex PTSD may experience symptoms such as:

• flashbacks, nightmares or intrusive memories
• feeling as if the trauma is happening again (re-living)
• avoiding reminders of what happened
• feeling constantly on edge, watchful or unsafe (on “red alert”)
• anger, irritability or sleep problems
• emotional numbness
• dissociation or feeling disconnected
• shame, guilt or feeling worthless
• difficulty trusting others or feeling close to people

NICE recognises that PTSD, including complex PTSD, can involve re-experiencing, avoidance, hyperarousal, dissociation, emotional dysregulation, relationship difficulties and negative self-perception. NICE also describes complex PTSD as involving PTSD symptoms plus severe and persistent difficulties with affect regulation, negative beliefs about the self, and difficulties sustaining relationships or feeling close to others.

Why Complex PTSD can be misunderstood

Complex PTSD can affect how a person copes with threat, closeness, conflict, criticism, shame, uncertainty and loss.

To the outside world, this may sometimes look like mood swings, withdrawal, mistrust, anger, “overreacting”, difficulty managing emotions or difficulty in relationships. But these responses may have developed as survival strategies in situations where the person’s nervous system had to adapt to danger, unpredictability, abuse, neglect, coercion or repeated stress. The person themselves might describe feeling as though they have “no happy medium”; moving quickly between feeling overwhelmed, shut down, anxious, angry, numb or intensely distressed.

This does not mean that every difficulty is caused by trauma. Nor does it mean that diagnoses such as BPD or EUPD are never meaningful to anyone. However, many people find it more compassionate and accurate to understand their difficulties in the context of what they have lived through.

At National Clinical Psychology Service, our Clinical Psychologists use psychological formulation. This means working with you to understand your difficulties in the context of your life experiences: how they may have developed, what may be keeping them going, what strengths and resources you already have, and what kind of therapy may be most helpful for you.

NICE guidance on PTSD recognises complex PTSD and recommends evidence-based psychological therapies including trauma-focused CBT and EMDR for PTSD, with additional attention to safety, trust, stabilisation, dissociation, emotional regulation and ongoing support where people have complex needs.

Is EMDR good for trauma?

EMDR, or Eye Movement Desensitisation and Reprocessing, is a therapy used for trauma and PTSD. For many people, EMDR can make trauma feel more manageable by approaching distressing memories in carefully paced, smaller parts, so the person does not feel they have to face everything all at once.

In EMDR, you do not have to describe every detail of the trauma in the same way that you might imagine in some talking therapies. EMDR usually involves identifying target memories, beliefs, emotions and body sensations, while using bilateral stimulation. This may involve eye movements, tapping or sounds.

NICE recommends EMDR for adults with PTSD in particular circumstances and says EMDR should be delivered by trained practitioners, in a phased way, with preparation, psychoeducation, work on distressing memories, positive beliefs and self-calming techniques.

Our EMDR page explains that EMDR can help people process disturbing memories so they can be “filed away” as something that happened in the past, rather than continuing to trigger a red-alert response in the present.

EMDR can be a powerful therapy, and many people find it helpful for trauma and PTSD. Since EMDR involves working with distressing memories, preparation, pacing and emotional safety are important. As Clinical Psychologists, we are very aware that people seeking trauma therapy may already have lived through overwhelming experiences, and we would not want therapy to feel overwhelming or re-traumatising. Your psychologist will work collaboratively with you, encouraging regular feedback so that the pace, focus and intensity of the work can be adjusted to your needs.

Is EMDR helpful for PTSD?

EMDR can be helpful for PTSD, especially when traumatic memories continue to feel vivid, intrusive, distressing or “stuck”.

People may seek EMDR because they experience:

• flashbacks or nightmares
• panic or body reactions when reminded of/thinking about what happened
• strong shame, fear, guilt or anger linked to trauma memories
• avoidance of people, places, conversations or situations
• feeling unsafe, even when they know they are no longer in danger

EMDR is not about forcing someone to relive trauma before they are ready. A skilled Clinical Psychologist will first help you understand what is happening, build emotional stabilisation strategies and agree when it is appropriate to begin trauma processing.

Is EMDR good for complex PTSD?

EMDR may be helpful for complex PTSD, but it often needs to be carefully paced.

With complex PTSD, there may be multiple traumas, early life experiences, attachment injuries, shame-based beliefs, dissociation, emotional regulation difficulties or relationship patterns that need careful attention. This does not mean EMDR cannot help. It means the preparation phase may be especially important.

NICE recommends that, for people with PTSD and additional needs including complex PTSD, professionals may need to build in extra time to develop trust, consider safety and stability, help manage barriers such as dissociation or emotional dysregulation, and plan ongoing support after trauma-focused therapy.

It is completely understandable that when people approach us for EMDR, they may hope for rapid relief from symptoms that have been painful, exhausting or disruptive for a long time. EMDR is sometimes spoken about as if it is a “quick fix” or standalone treatment, and for some people with single-incident trauma, the work may be relatively brief. However, with complex PTSD, the preparation stage is often a very important part of the therapy. Taking time to build trust, understand triggers, develop stabilisation strategies and agree a manageable pace is not a delay to treatment; it is part of making the trauma work more likely to feel safe, effective and sustainable.

For some people, EMDR may be offered alongside other approaches, such as compassion focussed work, CBT, CAT work, DBT-informed skills, ACT or other therapies, depending on the person’s formulation and goals.

What do I need to know before starting EMDR for trauma?

Before starting EMDR, it is helpful to know that:

• EMDR should begin with assessment and preparation, not immediate trauma processing.
• When you reach the processing stage, you and your Clinical Psychologist can agree which memories, themes or difficulties to work on.
• You can learn ways to manage distress between sessions before starting active trauma processing.
• It is important to discuss your experience of therapy with your Clinical Psychologist as the work progresses. You do not need to push yourself, or be pushed, beyond what feels tolerable. This is a time to look after yourself, including during therapy. At the same time, if avoidance is getting in the way of recovery, you and your therapist can think about this together. There is often a balance between appropriate self-protection and avoidance.
• EMDR may bring up strong emotions, images or body sensations, so pacing matters.

For complex PTSD, preparation may take longer, and that is not a failure on anyone’s part. It reflects the importance of building trust, safety, stabilisation and a shared understanding of what will make the work manageable.

A good question to ask is not simply, “Can EMDR work?” but “How do we make EMDR safe and appropriate for me?”

What is Trauma Focussed CBT?

Trauma Focussed CBT is a form of Cognitive Behavioural Therapy developed to help people process trauma and reduce PTSD symptoms.

It usually involves understanding how trauma affects the brain, body, emotions, thoughts and behaviour. It may include learning ways to manage arousal, reduce avoidance, process trauma memories, work with shame or guilt, and rebuild life after trauma.

NICE recommends individual trauma-focused CBT for adults with PTSD or clinically important PTSD symptoms more than one month after trauma. NICE also says trauma-focused CBT should include psychoeducation, safety planning, processing trauma memories and trauma-related emotions, restructuring trauma-related meanings, overcoming avoidance and re-establishing adaptive functioning such as work and relationships.

Is Trauma Focussed CBT helpful for PTSD?

Yes, trauma focussed CBT is one of the main evidence-based psychological therapies for PTSD.

It can help people understand why their symptoms make sense, reduce avoidance, process traumatic memories and change painful trauma-linked meanings such as:

• “It was my fault.”
• “I am permanently damaged.”
• “I am not safe anywhere.”
• “I should have stopped it.”
• “I cannot trust anyone.”
• “I am weak because I still feel affected.”

Trauma focussed CBT is not about telling people to “think positively”. When delivered by an appropriately trained and experienced clinician, it involves carefully understanding how trauma has shaped threat responses, beliefs, emotions and coping patterns, then helping the person move towards a life less controlled by trauma.

Is Trauma Focussed CBT good for complex PTSD?

Trauma focussed CBT can be helpful for complex PTSD, but it may need to be adapted.

For complex trauma, therapy may need more time for trust, safety, stabilisation, emotional regulation, shame, self-criticism, dissociation and relationship difficulties. A Clinical Psychologist can help decide whether to start with trauma processing, emotional regulation work, compassion focussed work, relational formulation or another approach.

Some people need EMDR. Some people need trauma focussed CBT. Some benefit from a combination or from a phased, integrative approach.

The important point is that therapy should be tailored to the individual, rather than trying to fit people, their histories and their difficulties into a rigid “one-size-fits-all” model.

What do I need to know before starting trauma focussed CBT?

Before starting trauma focussed CBT, it is helpful to know that:

• You will not be blamed for your trauma responses. People react to trauma in many different ways. Some responses are physiological or bodily reactions; others may have been the best ways you knew at the time to try to keep yourself as safe as possible.
• Therapy will usually include understanding how trauma affects the mind and body.
• You may work on avoidance, memories, beliefs, emotions and daily functioning.
• You may be asked to practise strategies between sessions.
• The therapy should be collaborative and paced.
• For complex PTSD, more sessions or a phased approach may be needed.

Trauma focussed CBT is not about minimising what happened. It is about helping your mind and body gradually learn that the trauma is no longer happening now.

Will EMDR or trauma focussed CBT be effective for me?

Dr Jurai Darongkamas, Consultant Clinical Psychologist, first began working in NHS mental health services in 1986 and has spent many years working with trauma-related difficulties, both directly with clients and through supervising other clinicians. Over that time, she has seen many people make substantial progress, including people who, after therapy, no longer met diagnostic criteria for PTSD. These clinical experiences are also reflected in the wider research literature, which shows that evidence-based trauma therapies such as EMDR and trauma focussed CBT can be helpful for many people.

No therapist or therapy can honestly guarantee a particular result for every person. The likely helpfulness of EMDR or trauma focussed CBT depends on many factors, including your trauma history, current safety and circumstances, emotional regulation, dissociation, support network, physical health, medication, substance use, relationship context, previous therapy experiences, readiness for trauma processing, the therapeutic relationship, and whether the duration and type of therapy are clinically appropriate for your needs.

However, PTSD and complex PTSD can improve. Many people do recover substantially from trauma symptoms with appropriate psychological therapy and a strong therapeutic relationship. Seeing people move from feeling controlled by trauma towards greater freedom, stability and choice can be deeply meaningful and rewarding; it’s been one of the reasons the author has remained in the profession for so many years.

At National Clinical Psychology Service, our Clinical Psychologists can help you think about:

• whether your difficulties fit with PTSD, complex PTSD or another understanding
• whether EMDR, trauma focussed CBT or another approach may be most appropriate
• how to pace therapy safely
• what preparation may be needed before trauma processing
• how to work with shame, self-criticism, emotional regulation and relationships
• how to move towards recovery in a way that fits your life

You do not need to know the exact diagnosis before getting in touch. See more on our About Us page or Contact us.

How to start recovery from complex PTSD

Starting recovery does not have to mean telling the whole story straight away.

It may begin with a first conversation, an assessment, or a formulation session where you and your Clinical Psychologist begin to understand what has happened, what you are experiencing now and what might help.

Recovery may involve:

• understanding trauma responses
• learning ways to calm the nervous system
• reducing shame and self-blame
• processing traumatic memories
• rebuilding trust in yourself and others
• changing patterns that once helped you survive but now keep you stuck
• developing a life less organised around threat

Complex PTSD can be painful, exhausting and isolating. However, it is not a sign that you are broken. It may be a sign that your mind and body have been trying to survive overwhelming experiences for a long time.

EMDR and trauma focussed CBT with Clinical Psychologists

At National Clinical Psychology Service, we have Clinical Psychologists offering EMDR and trauma focussed CBT for trauma, PTSD and complex PTSD.

We have several colleagues trained in EMDR, trauma focussed CBT and other psychological therapies (including Dialectical Behaviour Therapy / DBT informed and Mentalisation Based Therapy,  MBT and Cognitive Analytic Therapy, CAT). As Clinical Psychologists, we can draw on a range of evidence-based approaches and tailor therapy to your needs, rather than expecting one model to fit everyone.

If you are wondering whether EMDR or trauma focussed CBT could help you, you are welcome to enquire about therapy for PTSD, complex PTSD or trauma-related difficulties.

Enquire about EMDR or trauma focussed CBT
Contact us to ask about availability with one of our Clinical Psychologists.

For general PTSD therapy, see our page on PTSD treatment with Clinical Psychologists.

For broader trauma therapy, see trauma therapy with a Clinical Psychologist.

This article focuses specifically on Complex PTSD, sometimes linked with complex trauma, and how EMDR or trauma-focused CBT may help.

FAQ

Is EMDR good for complex PTSD?

EMDR can be helpful for complex PTSD, but it often needs careful preparation and pacing, especially where there are multiple traumas, dissociation, emotional regulation difficulties, shame or relationship difficulties. A Clinical Psychologist can help assess whether EMDR is appropriate and how to make the work as safe and manageable as possible.

Is trauma focussed CBT good for complex PTSD?

Trauma focussed CBT can help people process trauma memories, reduce avoidance and work with trauma-related beliefs. For complex PTSD, or trauma induced emotional regulation and interpersonal relational difficulties, therapy may need adapting and may take longer.

Can complex PTSD be mistaken for BPD or EUPD?

There can be overlap in emotional regulation and relationship difficulties. Some people find BPD/EUPD labels helpful, while others experience them as blaming or stigmatising. A trauma-informed psychological formulation can help make sense of the person’s history, survival strategies and current difficulties. One alternative descriptive term for some complex PTSD-related difficulties suggested in the clinical literature is TIERI, which stands for trauma induced emotional regulation and interpersonal relational difficulties.

Which is better: EMDR or trauma focussed CBT?

Neither is automatically better for everyone. The most appropriate approach depends on your trauma history, symptoms, preferences, current safety, readiness for trauma processing and psychological formulation. Some people benefit from EMDR, some from trauma focussed CBT, and some from a phased or integrative approach.

Do I need a diagnosis before asking for help?
No. You can enquire if you are experiencing trauma symptoms, PTSD symptoms, complex PTSD symptoms or difficulties linked to earlier life experiences.

What is TIERI?

One alternative descriptive term for some CPTSD difficulties suggested in the clinical literature is trauma induced emotional regulation and interpersonal relational difficulties, or TIERI.

See also our other page of FAQs on Clinical Psychologists generally