Reflection
Complex PTSD: When the Trauma Never Ended
Vietnam, and what PTSD was built to describe
Post-traumatic stress disorder came into general use after Vietnam.
The picture it was built to describe is a particular one. A man comes home. The war is over, the danger is thousands of miles away, and yet his head is still out there. Something happened, it ended, and it will not stop happening inside him.
That shape matters. PTSD as originally conceived describes the aftermath of an event: a bounded thing, with a before and an after, which the person survived and cannot put down.
A great many of the people I see do not have that shape at all.
The other shape
For them there was no event, because there was no interval between events. It was the weather. It went on for years, during the years in which they were being formed, and it did not so much leave a mark on their personality as help construct it.
That is what complex PTSD describes.
And it is a recognised diagnosis, with a caveat worth knowing. Complex PTSD appears in the World Health Organisation’s ICD-11 as a distinct category, alongside PTSD. It does not appear in the American DSM-5, which moved away from the idea. The originating clinical paper is Judith Herman’s, published in 1992, on the syndrome she observed in survivors of prolonged and repeated trauma.
So if you have been told that complex PTSD “isn’t real”, that is not quite right either way. It is formally recognised by one of the two major diagnostic systems and not by the other, and the disagreement between them is genuine rather than administrative.
The practical difference for a patient is this. PTSD asks what happened to you. Complex PTSD asks what it was like to live there.
What the diagnosis actually requires
Since it is a formal diagnosis, it is worth setting out what it consists of. Most writing on the subject describes the feeling and skips the criteria, which leaves people unable to tell whether any of it applies to them.
ICD-11 builds complex PTSD out of six clusters. The first three are the PTSD criteria: re-experiencing the trauma in the present, avoidance of reminders, and a persistent sense of current threat.
The other three are grouped together as disturbances in self-organisation. Severe and persistent problems in regulating emotion. Beliefs about oneself as diminished, defeated or worthless, carrying shame, guilt or failure. And persistent difficulty in sustaining relationships and in feeling close to other people. There must also be significant impairment in ordinary functioning.
One detail that surprises people: in ICD-11 the two diagnoses are mutually exclusive. If you meet the criteria for complex PTSD, you are not also given PTSD.
Hold on to those three self-organisation clusters. Everything in the second half of this article is a description of them from the inside.
Growing up around drinking
The clearest version I meet is someone who grew up with a parent who drank.
Nothing in particular happened, they will often say in the first session. There was no single incident they can hand me. And then over the following weeks it emerges that they spent fifteen years listening for a car in the drive, reading a face across a kitchen for the exact temperature of the evening, and managing the household mood of an adult who should have been managing theirs.
Uncertainty was the medium they grew up in. Not danger at intervals, punctuated by safety. Danger as the ordinary condition, with the timing unknown.
The fear does not require the violence
This is the part most often misunderstood, including by people who lived it.
You do not need to be beaten regularly for fear to organise your entire childhood. Sometimes it is a look. The alcoholic turns and looks at you, and in that second you understand, with total clarity, that he could kill you. Nothing follows. Nothing needs to.
Violence does not have to be frequent in order to be constant. A single episode can hold a household for weeks. It does not need repeating. One act purchases the compliance, and the fear does the rest of the work on its own.
Which is why counting incidents always underestimates the damage. Ask someone how often they were hit and the honest answer may be twice, and it will sound mild, and it will explain nothing about why they still cannot relax when someone raises their voice thirty years later.
The child cannot leave
An adult living with an alcoholic partner has, at least in principle, a door.
A child does not. You are living in the house. You cannot run away, you cannot end the relationship, you cannot decide the terms, and until you are old enough to leave you are effectively a hostage to somebody else’s condition. Everything you develop, you develop inside that.
That is the structural difference, and it is why this is not simply a more severe version of adult trauma. The person was assembled in the conditions rather than damaged by them.
And the shame that travels with it
Alongside all of it, shame.
Not shame at having been frightened, though there is often that too. Shame about the family, about the state of the house, about what might happen if a friend came round. The permanent low-level work of concealment, and the knowledge that the thing you are concealing is not your fault and is somehow still yours to hide.
Children of alcoholics learn very early not to bring people home. They also learn that the truth is unsayable outside, which makes for a life of managing impressions, and leaves intimacy much harder to learn.
What it looks like later
People do not usually arrive saying they have complex PTSD. They arrive with something else and the history comes out sideways.
What tends to be present, in some combination:
- A nervous system permanently set slightly too high. You are not anxious about anything in particular, you are simply ready.
- Great difficulty knowing what you feel, or what you want, having spent your formative years monitoring what somebody else felt and wanted.
- Trouble trusting, alongside a tendency to trust exactly the wrong people, because familiar and safe were never the same thing.
- Shame that behaves like a personality trait rather than a response.
- A strong pull towards looking after people, and considerable discomfort when attention turns to you.
- The sense of being an impostor in ordinary calm. Peaceful situations can feel less safe than difficult ones, because difficulty is legible and calm is not.
Look back at the criteria and you will see that this list is those three self-organisation clusters described from the inside: the emotion regulation, the self-concept, the relationships. They are not three separate problems that happened to arrive together. They are one adaptation seen from three angles.
None of it is a character defect. All of it made sense in the house it was learned in.
Why the same relationship keeps arriving
Briefly, because I have written about this at length elsewhere.
If you learned before you could choose that love means monitoring somebody, that your role is to hold things together and that your own needs come after the emergency, then you are unusually well equipped to tolerate a situation other people would leave in the first year. The role was learned early, and roles look for scripts. I have watched people leave one alcoholic and find another, or leave and find somebody who does not drink but still needs managing.
I should be honest that I see the people who come to see a psychotherapist, which is not a random sample of anybody, and plenty of people end up in a relationship like this with no such history at all. But where the pattern is there, it is worth knowing about, because it is what decides whether the next relationship is different.
I have written about that situation from the other side in living with an alcoholic.
On treatment, honestly
I have used EMDR for more than twenty years and it can do remarkable things with traumatic memory. I want to be accurate about it here rather than promotional.
Single-event trauma often responds well and sometimes quickly. A discrete horror, processed properly, can stop generating distress.
Complex trauma is a different proposition, though not quite in the way it is usually described. There is no single memory to process, because the problem is not one memory, it is fifteen years of ordinary Tuesdays.
And here I have to report a disagreement rather than a settled answer, because there is a real one.
The traditional recommendation comes from Herman in 1992 and was taken up by the international guidelines. Treatment should be phased: establish enough safety and stability first, then the traumatic material, then the longer business of building a life that does not run on vigilance.
That recommendation has been seriously challenged. A large group of trauma researchers argued in 2016 that the evidence for requiring a stabilisation phase is thin, and that insisting on one delays or denies people treatment that would have helped them. Randomised trials since have found that adding stabilisation to trauma-focused work for complex PTSD is effective but not necessary, and that trauma-focused treatments including EMDR do work for people whose trauma began in childhood.
So the honest position is that this is open. What I would tell you, if you were sitting in front of me, is which approach I am proposing and why, rather than presenting either as settled science.
What is less disputed is the scale of it. Reviews of standard trauma treatments in people with complex presentations find reliable improvement in self-concept and in relationships, with weaker evidence on the emotion regulation side, and smaller gains where the trauma dates from childhood. It works. It works more slowly here.
Anyone offering to resolve a childhood in six sessions is selling something.
Since the question behind the question is usually what the first part actually involves: stabilisation is not preparation in the abstract. It is practical. Recognising that you are activated before you are overwhelmed by it. Having something reliable to do at that point. Sleeping. Having enough ordinary steadiness in the week that a difficult session has somewhere to land. For some people that is two or three sessions. For others it is most of a year.
What actually changes
Not the history. That stays.
What changes is that the vigilance becomes something you have rather than something you are. You start to notice you are scanning, instead of simply scanning. You become able to tell the difference between danger and the feeling of danger, which sounds small and is not.
And attention turns, slowly and often uncomfortably, towards you. Most people in this position have not been asked what they want in a very long time, and have no immediate answer. Finding one is a good deal of the work.
If any of this is happening now
This article is about the long shadow of something that has usually finished. If it has not finished, that is a different and more urgent matter.
If you are frightened for your safety, the National Domestic Abuse Helpline is 0808 2000 247, free and answered at any hour. If you are in immediate danger, call 999. If you are struggling and need to speak to somebody tonight, Samaritans answer at any time on 116 123.
If you grew up with a parent who drank and you want to be around people who understand it without explanation, Al-Anon Family Groups run meetings for exactly that, and their helpline is 0800 0086 811, ten in the morning to ten at night.
Dr Philippe Jacquet is a UKCP-registered psychotherapist and Jungian analyst with more than 25 years in practice, over twenty of them using EMDR, including nine years working within private residential treatment. He offers trauma therapy in London and online, in English and French.
This article is educational. It does not constitute an individual assessment and does not replace psychotherapy, medical advice or urgent support.
