What treatment is best for Complex PTSD? Let's take a closer look at trauma work, DBT and EMDR
- Alexandra Zim
- 6 days ago
- 5 min read
The Difference Between Complex PTSD and Borderline Personality Disorder
Complex PTSD is a stress related disorder that creates extreme emotional dysregulation, avoidance of certain triggering situations, impulsivity, aggressiveness, heightened emotional responses, anxiety and difficulty sustaining long-term relationships. It is believed to be as a result of being exposed to long-term traumatic experiences such as childhood sexual abuse, war and chronic violence.
Complex Posttraumatic Stress Disorder has been heavily debated for years as to whether or not it even exists or is diagnosable. It is also often confused if not blurred with the much misunderstood Borderline Personality Disorder (BPD). This is because BPD is also thought to have developed from traumatic childhood experiences typically described as an invalidating parental environment.
Many people suffering from Borderline Personality Disorder also describe chronic sexual abuse, violence and unmet needs as a child. Clients with BPD experience emotional dysregulation (anxiety/depression), tumultuous relationships, problems identifying an intact sense of self and what many people would describe as toxic patterns of behavior. Drug and alcohol abuse are very common in both Complex PTSD and Borderline Personality Disorder. Also, anger, aggression, impulsivity and general chaos tend to follow both diagnosis.
Why is there a debate about how to treat Complex PTSD?
The acceptance of Complex Posttraumatic Stress Disorder (Complex PTSD) as a recognized diagnosis has led to large debate amongst practitioners regarding how to best treat this disorder using evidenced-based practices (therapy that actually works and effective based on research) . Supporters of unimodal approaches to PTSD have argued that trauma-focused cognitive behavioral therapies are recommended (NICE, 2018) and should be extended to the treatment of Complex PTSD (Resick et al., 2003). Other practitioners argue phase-oriented treatment plans are needed. Specifically, the phase-oriented practitioners argue that in everyday clinical practice, most clients with Complex PTSD are unable to tolerate trauma processing unless some preliminary work is conducted that helps them with coping strategies and a supportive therapeutic relationship (Dyer and Corrigan, 2021).
Primary unimodal interventions recommended include Cognitive Behavior Therapy, Cognitive Processing Therapy, Cognitive Therapy, Prolonged Exposure Therapy, Narrative Therapy, and Eye Movement Desensitization and Reprocessing (EMDR). All of these types of therapy have strong evidence in their effectiveness in PTSD populations and have been well-established in meta-analyses and randomized controlled trials (Dyer and Corrigan, 2021). On the other hand, the evidence for unimodal therapies is less comprehensive (Dyer and Corrigan, 2021), but emphasize three flexible stages for Complex PTSD therapy. 1) Stabilization, 2) Trauma Memory Processing, and 3) Reintegration.
For example, interventions such as STAIR Narrative Therapy, incorporate emotion regulation and interpersonal skills training in phase one and traumatic processing in the second, narrative phase (Hassija and Cloitre, 2014). However, phase-oriented treatment plans have been criticized for only including the first two phases of this approach, leaving out the third phase of reintegration (Dyer and Corrigan, 2021).
Gold and Ellis (2017) developed a conceptually based model grounded in a similar notion; namely, that leading multiply traumatized clients into directly addressing their trauma history early in treatment rapidly led to marked deterioration rather than improved functioning. Contextual therapy provides another lens to conceptualize Complex Trauma. Specifically, that the Complex PTSD picture in survivors of prolonged childhood abuse is accounted for not only by repeated/ongoing trauma, but also by the impact of growing up in a developmentally deficient family environment (Gold and Ellis, 2017).
What does this comparison and contrast mean for folks that want the best treatment for Complex PTSD?
It could be argued that the Contextual Therapy conceptualization effectively encompasses the three components of phase-oriented treatment plans because its aimed at fostering a collaborative relationship between the therapist and client that fosters a sense of security and intimacy (i.e., stabilization). Because of the client conceptualization, which seeks to help the client revise distorted beliefs, as well as develop the capacity for effective judgement and reasoning (i.e. trauma memory processing); And incorporates therapist-guided skills, which are designed to equip the client with the capacities for daily living (i.e., reintegration) (Gold and Ellis, 2017).
It is important to note that Contextual Therapy conceptualizes trauma survivors based on the context in which the traumas occurred: a deficient family environment (Gold and Ellis, 2017). Therefore, this conceptualization differentiates Contextual Therapy from phase-oriented therapies and ultimately provides the framework for the three-component model in Contextual Therapy.
Lastly, Contextual Therapy emphasizes considering the larger social, economic, political, and cultural backdrop when treating survivors of PCA, which has been supported by the New Haven Trauma Competency Group (2014) as a competency for foundational knowledge in treating trauma. Overall, it would be interesting to test the efficacy of Contextual Therapy compared to other phase-oriented treatments and unimodal approaches to PTSD.
Is there an alternative until we have more research?
For now, based on the fact that Complex PTSD and Borderline Personality Disorder presents in such a similar fashion, it makes sense to conceptualize both types of therapy cases from a Dialectical Behavioral Therapy model. It would stand to reason that if people suffering from BPD respond well to DBT and people with Complex PTSD have had similar childhood experiences, that DBT for now (until more research is done) is the most clinically indicated route to take when treating people who have experienced a lot of childhood trauma and are currently struggling with emotional dysregulation, emotional intensity and chronic relationship problems.
EMDR
There is still more research to be done on how EMDR (Rapid Eye Movement Desensitization and Reprocessing) could play a role into these different types of therapies. It is well documented that EMDR is clinically indicated for PTSD. More studies and metanalysis is needed to discover if it is suitable for Complex PTSD. One hypothesis could be that EMDR may be more effective, after DBT is already implemented.
If you or anyone you know might be suffering from Complex PTSD, Call today to schedule an appointment with one of our therapists that specializes in Dialectical Behavioral Therapy (DBT) and trauma therapies.
References
Cook, J. M., Newman, E., & The New Haven Trauma Competency Group (2014). A consensus
statement on trauma mental health: The New Haven Competency Conference process and major findings. Psychological Trauma: Theory, Research, Practice & Policy, 6(4), 300-307. https ://www.apa.org/pubs/journals/features/tra-a0036 747.pdf
Dyer, K. F. W., & Corrigan, J. (2021). Psychological treatments for complex PTSD: A
commentary on the clinical and empirical impasse dividing unimodal and phase-oriented therapy positions. Psychological Trauma: Theory, Research, Practice, and Policy, 13(8), 869-876. https://doi.org/10.1037/tra0001080
Gold, S. N., & Ellis, A. E. (2017). Contextual treatment of complex trauma. In S. N. Gold
(Ed.), APA handbook of trauma psychology: Trauma practice (Vol. 2); APA handbook of trauma psychology: Trauma practice (Vol. 2) (pp. 327-342, 599 Pages). American Psychological Association. https://doi.org/10.1037/0000020-015
Hassija, C. M., & Cloitre, M. (2014). The Skills Training in Affective and Interpersonal
Regulation (STAIR) narrative model: A treatment approach to promote resilience. The resilience handbook: Approaches to stress and trauma; The resilience handbook: Approaches to stress and trauma (pp. 285-298). Routledge
National Institute for Clinical Excellence. (2018). Quick Reference guide: PTSD (Clinical
Guidelines 26).
Resick, P. A., Monson, C. M., & Chard, K. M. (2017). Cognitive processing therapy for PTSD.
Guilford Press.
