Complex PTSD

Some people develop a particular pattern of difficulties after trauma that happened again and again, or went on for a long time. It builds on post-traumatic stress disorder (PTSD), and it’s called complex PTSD. Therapy helps with many of those difficulties. Research on treating complex PTSD itself is still catching up, and here’s what’s known so far about what helps, and why.

What the term describes

Complex PTSD includes everything in PTSD: memories that intrude, avoiding reminders, and a constant sense of threat. It also brings three difficulties that last. Emotions can be very hard to manage. People often see themselves as worthless or defeated, with deep shame or guilt. And it can be hard to stay close to people or keep relationships going.

Complex PTSD most often follows trauma that was repeated or went on for a long time. Usually it was hard or impossible to get away from, such as ongoing abuse or violence. That kind of trauma makes complex PTSD more likely, but it doesn’t define it.

Only a proper assessment can say whether the term fits, and whatever it’s called, the difficulties it describes can be worked on.

Where the diagnosis stands

Complex PTSD is included in the World Health Organization’s International Classification of Diseases. The Diagnostic and Statistical Manual of Mental Disorders, the other system clinicians use to diagnose, doesn’t list it on its own. So whether a clinician uses the term can depend on which of the two they work from.

Australia’s trauma guidelines include complex PTSD for the first time in their current edition (Phoenix Australia, 2020–21). They don’t recommend any treatment for it specifically, because the studies needed don’t exist yet. Instead, they describe an open question: do the treatments that work for PTSD work as well for complex PTSD, or do they need changing?

What helps

A review of 51 trials looked at therapy for PTSD (Karatzias and colleagues, 2019). The people in those trials were likely to have some of the extra difficulties that come with complex PTSD, but they weren’t diagnosed with it as such.

Trauma-focused cognitive behavioural therapyCognitive behavioural therapy (CBT) A structured, practical form of talking therapy. It's built on a simple idea: what you think affects how you feel, and both affect what you do. More in the jargon decoder Close (CBT), exposure-based therapy, and eye movement desensitisation and reprocessing (EMDREMDR (eye movement desensitisation and reprocessing) A structured therapy for memories that still feel raw. You bring a painful memory to mind for short stretches while your attention is split, usually by following your therapist's hand as it moves from side to side. The aim is for the memory to become less upsetting. More in the jargon decoder Close) all helped PTSD symptoms more than usual care. CBT and exposureExposure (facing things in steps) Facing what you've been avoiding, a bit at a time, and staying long enough for the alarm to settle. For fear and anxiety, it's often the part of therapy that does most of the work. More in the jargon decoder Close therapy also helped with how people saw themselves. All three helped with relationships. There was little data on managing emotions, and very little on EMDR and how people saw themselves.

The gains were smaller when these therapies were compared with general supportive contact. These therapies helped across the trials, though on average people whose trauma began in childhood improved less. EMDR and talk therapy compared looks at how these approaches differ in practice.

Other approaches are used for long-running trauma too. There’s early evidence for schema therapy, which works on emotional patterns that go back a long way. Some therapists use internal family systemsInternal family systems (IFS) A therapy that starts from the idea that your mind isn't one voice. It treats having different parts as normal, and works with those parts directly. More in the jargon decoder Close (IFS) or narrative therapyNarrative therapy A therapy built on one principle: you are not the problem, the problem is the problem. It works on the story you tell about your life, including what that story leaves out. More in the jargon decoder Close with long-running trauma. The research behind both is thin.

Steadying first, or starting sooner

Clinicians disagree about the order of treatment. Some think people first need time to build skills for handling emotions and relationships. Others think that delays work on trauma memories that could help sooner.

One trial looked at 149 adults with PTSD after childhood abuse (Oprel and colleagues, 2021). Some had eight sessions of skills training before exposure therapy. That didn’t lead to better results than exposure therapy alone. All the versions tested, including a faster, more intensive one, led to large improvements, and people coped with them well, but the question isn’t settled.

In practice, what matters most is that the pace is agreed between you and your therapist, and that you can say when it’s too much.

The relationship matters more here

Australia’s trauma guidelines say trauma treatment rests on a strong working relationship with your therapist. They add that this can take longer to build after trauma that went on for a long time. Why who you see matters more than what they do explains why that relationship counts for so much.

Therapy for long-running trauma often takes longer. Therapy and medication covers what’s known about medication alongside therapy.

Safety first, and support between sessions

If you’re still somewhere you’re not safe, or someone is hurting you now, safety comes before any work on what happened.

If you’re experiencing family, domestic or sexual violence, 1800RESPECT is on 1800 737 732. 13YARN, on 13 92 76, is crisis support for Aboriginal and Torres Strait Islander people.

The Blue Knot Helpline, on 1300 657 380, is for adults who went through trauma or abuse as children. It offers phone counselling and referralsReferral A letter from a GP, psychiatrist or paediatrician that you need for the Medicare rebate. You can see a psychologist without one if you pay the full fee. More in the jargon decoder Close from 9am to 5pm eastern time, seven days, and it supports partners, family and friends too. Blue Knot isn’t a crisis line. If you need help urgently, the numbers at the end of this page are there any time.

If you’ve served in the Australian Defence Force, or you’re family of someone who has, Open Arms offers free counselling on 1800 011 046, 24 hours a day.

Paying for longer therapy

How you pay shapes how long you can keep going. Paying the full fee has no session limit, and that includes seeing a counsellorCounsellor Someone trained to help people talk through and work on difficulties. The title isn't protected in Australia, so it's worth checking a counsellor's training and registration. Medicare doesn't give a rebate for counsellors. More in the jargon decoder Close or psychotherapistPsychotherapist Someone trained in therapy, often for longer-standing patterns. Like counsellor, the title isn't protected in Australia, and Medicare doesn't give a rebate for psychotherapists. More in the jargon decoder Close, whom MedicareMedicare Australia's public health insurance scheme. For mental health, it gives rebates on sessions with psychologists and some other professionals, usually through a Mental Health Treatment Plan. More in the jargon decoder Close doesn’t cover. Workplace programs and community services usually offer a set number of sessions, and headspaceheadspace A national youth mental health service for anyone aged 12 to 25, with centres around Australia and support online and by phone. It's free or close to it, you don't need a referral or a parent, and you can book it yourself. More in the jargon decoder Close offers free or low-cost support for people aged 12 to 25. A group, where one is suitable, usually costs less per session.

A Mental Health Treatment PlanMental Health Treatment Plan A document your GP writes with you. It makes you eligible for a Medicare rebate on up to ten individual sessions a calendar year: six, then a review with your GP, then the remaining four. The plan itself isn't therapy. More in the jargon decoder Close from your GPGP (general practitioner) For most people, where getting help starts. A GP can write a Mental Health Treatment Plan, prescribe medication and refer you on, and some are trained to deliver a small number of structured therapy sessions themselves. More in the jargon decoder Close gives a Medicare rebateRebate The amount Medicare pays back towards a session. It comes back to you after you've paid, so what you pay yourself is the fee minus the rebate. More in the jargon decoder Close on ten sessions a calendar year. Ten sessions a calendar year is a funding limit, not a judgement about how much therapy anyone needs. Free and low-cost options covers other ways to keep costs down.

Kids Helpline is on 1800 55 1800, any time, for anyone aged 5 to 25. Lifeline is on 13 11 14 and, if you’re 15 or over, the Suicide Call Back Service is on 1300 659 467. In an emergency, call 000. Crisis and emergency support has the full list.

Where next

EMDR is one of the best-researched trauma therapies. Its page explains how it works.