(Patrick Hruby / Los Angeles Times)

This story was originally published in Group Therapy, a weekly newsletter answering questions sent by readers about what’s been weighing on their hearts and minds. Sign up here to get it in your inbox.

If there’s one truth that applies to all people, it’s that we’re shaped by our experiences.

The events of our lives — the good, the bad, the seemingly mundane and the devastating — play a key role in determining how we relate to ourselves and others, and whether we feel safe in our bodies and in this world.

This week’s newsletter is about complex trauma, which can happen when we survive repeated or long-term danger (emotional and/or physical), including childhood abuse or neglect, intimate partner violence, poverty and racism.


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A Group Therapy reader sent us a question about complex traumatic stress disorder, a relatively new diagnosis in psychology that’s thought to affect 1% to 8% of people worldwide: “I deal with chronic C-PTSD (complex post-traumatic stress disorder) symptoms and am often in emotional flashbacks. The day-to-day is incredibly hard, and I find myself often getting lost in the swirl of how much more I have to go — likely, years/a lifetime. What do you recommend to start small/keep hope on particularly rough days?”

Before we get started, I wanted to note that this newsletter may be hard to read for some. If you think this topic might apply to you and feel it would help you to learn more, read on. If you think it could destabilize you, it might be best to sit this one out.

We’ll touch on the history of the C-PTSD diagnosis, how complex trauma can affect a person’s quality of life, and what recovery from the condition can look like. We’ll also directly address our reader’s question: How do you stay hopeful amid the ups and downs of healing? I spoke with two psychotherapists specializing in trauma treatment and Stephanie Foo, author of the incredible book “What My Bones Know: A Memoir of Healing From Complex Trauma.”

What is complex trauma?

You’re likely familiar with the term post traumatic stress disorder, or PTSD. It’s been 43 years since PTSD became an official psychiatric diagnosis, and it now sits firmly in our collective awareness as the condition that commonly affects those who survive war, sexual assault, natural disasters and other catastrophic events.

Complex PTSD, on the other hand, is a fairly new term in the psychological lexicon. Psychiatrist and scholar Judith Herman proposed the diagnosis in 1992 after observing that the PTSD symptoms outlined in the “Diagnostic and Statistical Manual of Mental Disorders,” the diagnostic handbook used by mental health clinicians in the U.S. , didn’t fully capture the challenges of people who’d been repeatedly exposed to trauma over months or years.

Repetitive experiences that can lead to complex trauma include repeatedly witnessing or surviving violence; psychological, emotional, physical or sexual abuse; forced separation from homelands; and childhood neglect and abandonment. What’s common in these experiences and what ultimately creates enduring trauma is the inability to escape the situation and a feeling of powerlessness — that nothing you do can or will change what’s happening to you, said Natalie Gutierrez, a psychotherapist in New York who specializes in trauma.

Although C-PTSD and PTSD can be caused by different kinds of trauma, they share similar symptoms. These include the re-experiencing of the trauma through intrusive memories, flashbacks and nightmares; avoiding people, places and thoughts that remind you of the trauma; hypervigilance (being alert at all times to the possibility of danger); and frequent thoughts and emotions that are uncomfortable or painful.

According to the International Classification of Diseases, C-PTSD features three additional categories of symptoms beyond those that define PTSD: trouble regulating emotions; a negative sense of self shaped by feelings of shame, guilt, failure and worthlessness; and difficulty forming and maintaining relationships.

“If you have complex trauma, you may feel internally chaotic,” said Michael Quirke, a psychotherapist in the Bay Area. “This kind of trauma shapes our nervous systems. So you might be having fight, flight or freeze reactions all the time and not even know it. You may often feel disconnected from yourself and others. Or you could feel chronically depressed. It’s also quite common that people with C-PTSD avoid relationships.”

That’s because so many of the original wounds that lead to C-PTSD happened in relationships, Gutierrez said. “So much of it is an inability to allow ourselves to be vulnerable, because when we’ve been vulnerable, we’ve been hurt,” she said.

However, there remains some debate among experts on how to classify the experiences of those who live with these symptoms.

Complex PTSD wasn’t included as a separate diagnosis in the DSM-5 because 92% of people with C-PTSD also met the criteria for PTSD, according to the National Center for PTSD. Because it’s not in the DSM, some doctors and therapists don’t know about the condition or decline to diagnose it.

Advocates argue that recognizing C-PTSD as its own condition is vital to people getting adequate care. Foo, who was diagnosed with the condition at age 30, spelled out the importance of the distinction in her memoir.

“If I had traditional PTSD,” Foo wrote, “if, let’s say, getting hit by a car was the one foundational traumatic moment of my life, I could learn to isolate and resolve the triggers from it” Foo wrote, “ … but unfortunately, I do not have one foundational trauma. I have thousands.”

For some people who survive a long-term traumatic environment, it can be hard to believe that what they experienced was traumatic, because it doesn’t always fit the description of “Capital T” trauma as it’s understood under a PTSD diagnosis.

“Being given the tools to recognize that this continual distress was not ordinary and that it may have had significant impacts on your mind and body is often an important first step in treating C-PTSD,” writes mental health advocate Heidi Fischer.

What can C-PTSD recovery look like?

Even though complex trauma has yet to be fully validated by the medical establishment, many have dedicated their careers to helping people recover from it.

There are a growing number of psychotherapy approaches too, which are designed to work with trauma — like internal family systems (IFS); somatic experiencing; eye movement desensitization and reprocessing (EMDR); and trauma-focused cognitive behavioral therapy (TF-CBT).

Everyone’s healing journey is different because trauma manifests in so many ways. What works for one person won’t work for another. “The trick is really experimentation,” Foo said. “There’s not one silver bullet.”

I asked this week’s experts to talk about how complex trauma can be healed. Many of the elements they mentioned play a role in the above therapies.

Finding safety in our bodies:

Trauma leaves our bodies bracing (quite literally) to be hurt again. Certain conversation topics, places, people, smells, sounds or stressful life events might activate the more primal parts of the brain that regulate emotions and trigger our fight-flight-freeze response — even when there’s no actual threat to our safety. These automatic reactions can include shutting down (dissociating) or feeling overwhelmed, angry, vulnerable, panicky, tense or stiff. This is the way our bodies have learned to protect us.

When we’re not in danger anymore, these survival mechanisms get in the way of us feeling at ease in the world and nurturing meaningful relationships. That’s why working with the body first is essential, Quirk said.

Quirk sometimes gets new clients who have a lot of experience with talk therapy but not much has changed; they’re still triggered by the same stuff. That’s because they haven’t built safety in their bodies, he said.

“In order to recover, you need to know when you’re being triggered,” Quirk said. “If no attention has been given to what’s going on in your body your whole life, this is a developmental leap. It can take a while.”

Gutierrez sees healing the body as “reclaiming” the body, especially for marginalized folks — “fat bodies, trans bodies, gender-nonconforming bodies, bodies of color, bodies with disabilities, and survivors of sexual trauma and physical violence,” she said.

She helps her clients notice when and how often they’re feeling unsafe. How often are they holding their breath, or when is their breathing shallow? In what kind of situations are they unable to sit still?

“And then we can learn to re-introduce breath back into the body to slow down our heart rate and relieve tension,” Gutierrez said. “We can also do this through body scanning, movement, stretching — whatever folks have access to in the moment to really calm their bodies, multiple times a day, to de-activate the stress response.”

Processing old memories:

Once you’ve become more attuned to your body, the next phase of healing is often processing old, painful memories associated with the trauma, Quirk said, ideally with a trained psychotherapist.

Finding safety with others and finding meaning:

Because C-PTSD is such a relational condition, a big part of healing is learning how to trust other people.

“Whether that is group therapy, joining a volleyball team, a sewing group or having a therapist who really connects with you, or a really loving partner or best friend,” Foo said. “Whatever it is, it’s about learning how to find safe, loving people, and how to rupture and repair with them” instead of avoiding conflict.

Gutierrez envisions this healing on a community scale. “How do we accept our humanness and take care of each other, without seeing each other as threats?” she asked. “How do we come together and have conflict as a community in a healthy way and begin to see each other vulnerably, with grace?”

Once you’re out of survival mode, and you’re not buffeted about by intrusive memories or emotional flashbacks, you have the capacity to consider other areas of your life where you’d like to cultivate meaning, like your career and hobbies. “You can be future-oriented,” Quirk said.

An answer for our reader

Our reader asked how they can keep hope on particularly rough days, because they know that healing from complex trauma can take a long time.

I asked our experts to answer this one directly.

“Until we are finished with this life, we will be healing, we will be growing,” Gutierrez said. “Try not to focus on all the healing work you have to do for the next several months or a lifetime. Taking it in all at once can be overwhelming. What is the healing work you have to do today? How can you be intentional about today? How do you take care of yourself today?”

Foo says it’s been important for her to appreciate the small wins along the way, even when things feel really hard.

“I think we can be really hard on ourselves if we don’t improve immediately, but that’s not how healing works. It takes time. But maybe, one day, you’re able to let yourself cry about something. That’s a win. Maybe instead of grabbing a drink, you’re able to feel better by sitting at the park and just breathing. Or maybe you are able to actually hear somebody and you don’t let your triggers get in the way of it,” she said. “One choice at a time, you’re reworking your neural pathways. Every time you connect with someone, you choose to not run away and confront hard feelings and be in this world. It’s kind of a miracle, a major success, a triumph.”

Foo recommends writing these wins down in a journal, or asking family, friends or your therapist, “Do you see me growing? Have you seen changes?” It could be really encouraging to hear their reflections.

“Keep the faith,” Foo said. “It does get better over time. There’s a really beautiful and bright light on the other side.”

Until next week,