27+ things to consider when working with clients with CPTSD

Part of an ongoing series about life with complex post-traumatic stress disorder

I like to think of therapists as guides, helping us to discover and explore aspects of ourselves and our histories. Shining a flashlight into those blind spots that we might not want to see, or finding paths down roads that look too tangly or overgrown to venture down alone. Sometimes we disagree about where to go next, but we chart a path together as thought partners.

As someone with CPTSD, opening up to journeys like this that spell danger, risk, and newness can be very scary, triggering, flashback-worsening, etc. So it’s especially important to me that I provide as much context as possible for my counselor and others about what makes therapy approachable and safe for me. Here is a long list of things to consider, and maybe more importantly, why you might consider them. You might disagree with some of them, or they may be counterintuitive, but from my perspective, these are all things that would be, or are helpful for, treating someone who — for you technical PhD’s out there — “meets the proposed criteria for CPTSD, DES-NOS, or DTD”.

1. Consider being very gentle with your phrasing. Avoid phrases like “Well of course you…” that could come across as condescending or dismissive. This might cause clients sensitive to power dynamics or authority figures to clam up or feel scared (instead try, “it makes sense that” or “I can see how you would…”). Be gentle when suggesting preferred terminology — like “functional” instead of “normal” or “dysfunctional” instead of “crazy”. It’s a big deal that these folks are opening up to anyone, so remember that it’s not always about being technical, or that you can just as easily say, “that’s a good point, sometimes I call that ____” to teach as saying, “we shouldn’t use that word, we must use ____ instead”, which can feel more punitive. Remember that these clients are often used to being lectured, critiqued and nitpicked ad infinitum and that you are coming from a place of knowledge and authority when they are being most open and raw.
2. Consider telling clients explicitly that it is ok to have opinions and express them in your therapy space. Their normal spaces are not like that. Tell them repeatedly it is normal and safe to have needs and feelings as a human. Whatever you might assume is obvious about human rules of behavior, is probably not obvious to them. While their lexicon might be adult, their knowledge of appropriate interpersonal skills may be that of a young child, especially when it comes to close relationships. Even if they seem adult, privileged, or put together.
3. Consider giving excerpts to read instead of assigning full books (or assign chapter by chapter). And, preface any reading assignments with the reminder that it may be harder to read than a usual book, because reading about trauma is often triggering.
   Reading homework can be hard for your clients, because books you give them about trauma or codependency will be triggering. It is dramatically harder to process information when every three pages, you might feel like vomiting, forget to breathe, have flashbacks of yourself being abused, or your brain tells you you’re worthless and there’s no point in trying to improve. So, assign books in specific increments, and discuss a plan in advance of what to do if someone is triggered by the reading. Otherwise, it feels like reading one of those books from the Hogwarts library that scream when you open it, or punch you for taking a book out of the restricted section.
   An example approach might be, “Hey, I’d like you to read the inner critic section of ‘Surviving to Thriving’ this week by Walker. Just a note that he has a lot of stories about his clients that will be both helpful and potentially triggering for you. Your inner critic might also have a lot to say to you after seeing itself called out on its pages. If you have a flashback, can you tell me what steps you’ll follow? Ok, good. If you hear your inner critic, I want you to tell it…”
4. Consider using repetitive, incremental assignments (you’re trying to hack into the reptilian brain).
   Your clients are most impaired when they are dissociated, stuck in the past, or complete frozen with amygdala hijacking. That is when they need grounding techniques and other support the most. But those moments are physiologically different, like when you see an accident about to happen, and time slows down and you feel frozen, afraid. Could you remember a complex list of steps in a moment like that? Probably not. So make assignments very simple, and make it something that you can build on. Have them list their three grounding techniques to you every single week, until it’s a reflexive thing they say to you as they leave. Once they can rattle them off, then it’s ok to start learning more.
   Another way to think of this, is that you’re like the physical therapists or personal trainers of self-talk and emotional regulation. Any PT will tell you it takes 4 sessions or so for someone to really get an exercise down. If you change it up every week or don’t check in on progress, people do not learn. So ideally, pick exercises carefully and make it something they can practice in under five minutes every day…so that they’ll do it every day. Help them practice defeating codependency on the way to the office. Help them practice standing up to themselves when they’re being harsh. Help them practice accepting themselves when they feel weak and flawed — by keeping things simple and incremental.
   Don’t say something overly general and hard to interpret like, “This week, I’d like you to practice self compassion”. Show your client what that looks or sounds like. E.g., “This week, let’s focus on self compassion. Whenever you say something mean to yourself, I’d like you to also say to yourself , ‘you are worthy of love and respect. I am glad to know you in all your forms. I am going to get through this.’ If that resonates with you, let’s say it three times together…Cool, would it help to write that down on this post it, and keep it in your pocket in case you forget?”
5. Check their incidence of flashbacks, but also, “flash forwards”. A form of hypervigilance or intrusive thoughts that is way more common that people think, what I call “flash forwards”, feel as real as flashbacks, but they haven’t happened yet. For example, when I walk down a busy street, I see in my head an instant replay of a car flying off the road and careening into me. When I lean in to kiss someone new, I see them in my mind’s eye hitting me in the face instead of giving me a kiss. These “flash forwards” can give you a lot of information about the past trauma someone experienced, and often inhibit aspects of daily life the same amount as flashbacks because they are so dissonant and disconcerting. But they are so normal to people with PTSD, that they are not something most would think to bring up (I think for many people they occur 3–10x a day). The closest example I’ve seen of this in media is in the tv show “Sex Education” Season 2 episodes 3 and 4, where a character starts seeing every man as the person who assaulted her on the bus. I’ve heard some people in the complex trauma community refer to them as their “negative daydreams”.
6. Consider helping us prepare for the holidays and traumaversaries, even when we think we might not need it. For us folks, holidays were often times to dread as children. Help us think through: contact level, boundaries, what we want vs. what others will want, what we’d like to be different from past years, how time will be spent, who key difficult actors might be, and strategies to deal with them. Even for folks with less contact or no contact, think through things like what to do if someone reaches out to you unexpectedly, or how to retain aspects of tradition they enjoy while creating new ones, themselves. There are also holidays that have societal expectations involved that tend to sneak up on us on the calendar — I find Mother’s and Father’s Day especially conflicting. All of these things are not fun to think about, but on the actual days can lead to raw emotions, freeze responses, the need to mourn what you wish you could have had, etc. if they’re not ready.
7. Consider conducting role plays to help clients prepare in a supportive setting, prior to trying to set boundaries or do battle with the advanced level tornadic vortexes of toxic people in their lives. Start as simple as possible with the very basics, like, how to end a phone call you do not want to be on. Most of us are not used to, and do not know how to identify and stand up for our needs. Trying to practice new methods against people who do not respond in functional ways does not reinforce that the methods are working, worth it, or valuable. It’s like trying to play on video game level 30 against a super villain, without having a chance to ever play level 1, if you do not help us practice on people who are able to respond functionally.
   For example, set up constructs to help us practice turning down an activity we’d not enjoy with you or a friend (I’d prefer to work on DBT skills today, instead of discussing my dreams, because…/I’d really prefer to go to the museum, instead of swimming tomorrow), before saying no to a family gathering (which might result in guilt tripping antics, war dialed phone calls, tons of texts, and accusations of disloyalty from family). We need enough positive feedback to gain confidence in what is normal, before being able to engage functionally and firmly in the abnormal.
8. Consider demonstrating that your office is sound proofed. Also, consider closing the blinds if you are on ground level, or can see others walking past or in the distance from your office windows. It is hard to feel relaxed if you are in any way able to be observed by the unknown. People with CPTSD have a lot of constructed personas and pretenses to keep themselves safe, and those can’t come down in session if you think the people next door can hear you, or someone outside might see you. It doesn’t matter if those people are strangers; because of hypervigilance, they can still feel dangerous or like they might have unknown power over us in the future.
9. Consider having a HIPAA compliant communications portal. People with CPTSD maybe be used to being constantly monitored, and may not trust less secure networks. These clients have seen the worst of human nature and may have a clearer grasp on risk than you do. Respect it and provide a space for safe communication.
10. Consider soliciting regular feedback from them to help them practice articulating needs and preferences. Tell clients directly what to do with their personal needs. It is confusing to people who are very used to ignoring themselves. Do they tell someone? What does that sound like? Practice by soliciting feedback. Ask what they are liking or not liking once a month, or if anything is bothering them. Be receptive and thoughtful of what they say. They will probably not share major gripes right away even if they have them. But be someone they can practice getting communication wrong with and encourage them when they tell you if something you are doing is bothering them. Congratulate them for being brave enough to share. For many people with CPTSD, we are stuck living in constant fear of having the wrong needs.
11. Clearly tell them in advance what to do if they have a flashback in session. Maybe, even occasionally ask them if they are in a flashback during a session, just to check. I once spent a whole session in a flashback and did not tell my therapist. I didn’t know how to speak up, and she had triggered me and I was worried I’d upset her if I told her. Watch for small cues like if someone asks for general help with grounding. When you do help with grounding, keep the techniques short, specific, and ask your client to practice them with you in person. Keep in mind you may not be able to tell they are in a flashback. I can spend large amounts of my day in emotional flashbacks. If people could tell easily, I don’t think I’d be able to have a job. A good tell — at least for me — is if I am completely unable to discuss myself personally or any of my feelings in a conversation.
12. Consider being very gentle about changes in routine or schedule. You don’t know how much someone else might be depending on you, and people with CPTSD are not always as able to handle sudden changes or adaptations. They can be triggering especially in terms of abandonment reactions. If possible, preface conversations as changes as best you can. For example, “I’d like to shift the conversation to talking about some logistics now. Is that ok with you, or would you prefer to discuss at the end of the session? Ok, there are some changes that may impact you. They do not affect how much I care about seeing you or how willing I am to work with you, and are not based in how much I like you. They are just part of my natural scheduling. On that note, I will be on vacation for two weeks a month from now. Here are two options for what we can do for coverage during that time…Are you feeling up to discussing which ones you would prefer right now, or do you need some time to consider it?”
    This is much gentler than someone springing an out of office on someone, or moving a scheduling slot on short notice, etc. In particular, be very careful making any promises to CPTSD clients, because they may remember them for years and be very upset if you do not follow through (do not say to a CPTSD client, “I promise I will always be here for you. Wednesdays are our time together!”).
13. Consider asking to see their calendar if they seem to be overachieving or always trying to be productive. They might be scheduling every minute of every day in flight responses/need to control. A lot of people need help scaling this back, but don’t know where to start. You can try by having 1–2 days a month of undetermined time to just be, or even an afternoon, and see how it goes.
14. Consider that their outside expressions will often rarely match their internal experience. If someone hit you every time you cried or became angry, you’d probably learn to look happy most of the time. That is literally the experience myself and others have had. Consequently, people assumed that I was happy for years even as I struggled with anxiety, depression, and CPTSD. Be aware of this and do not assume your clients with a smile, or stoic nature, are smiling inside. Many times, we do not know how we feel. Consider even using a feelings chart, and having us use it to identify how we feel at the beginning of each session to clue us — and you — into our inner experience. “How are you doing?” can be a mystifying opener for us.
15. Because of this, it is especially crucial to consider having quantitative score tracking for these clients. Consider doing the PHQ and GAD scoring monthly at least. And, make sure you define the criteria clearly, and provide private areas for their completion. I used to be so embarrassed to be having any difficulties that I found ways to underreport if I had to score myself in session, in front of a therapist. I might cry if I had to be honest, and in my world, crying = being hit, remember?
16. Be especially aware that mental health help, psychology, or psychiatry may have been villainized or demonized in their homes. Abusers of people with CPTSD can be natural enemies of the mental health field, because they are insecure and frequently uninterested in learning to be self aware. That means that home rhetoric may have been extreme towards mental health. In another common case, people with CPTSD may have been dragged as children into psychology or psychiatry offices by their families to be “fixed” by their abusers through medication or counseling because they were being “bad” children. Check with your clients to see how mental health help was treated or stigmatized in their homes to have a sense of how big of a leap it is for them to be seeing you, or how much work it may be to help them consider other treatments like psychiatry or other modalities.
17. Keep in mind they might be the most able to side track you, out of all your clients. People with CPTSD are used to distracting, calming, or placating family members who might be in an alcoholic rage, manic, psychotic, under the influence of substances, or who have serious emotional insecurities or issues. Distracting counselors away from scary topics is a cakewalk compared to that, and we might not even realize we are doing it. If you hear an absence of “I” statements or feeling words in the conversation for longer than a few minutes, they might be wandering you away from some form of discomfort. There are so many things that are easier to talk about, that it can be hard to resist sometimes.
18. Consider giving them resources for family members to best support them at home. These are clients who struggle to know their needs and feelings. Help their families figure things out with them. Give a simple step by step guide of five ways to ground someone (not twenty or thirty). Have a list of books, but even better a list of articles someone can read in under 20 minutes abut what complex trauma is and what people should expect at home. Big books are not spouse-friendly and feel like major asks from partners who may already be overstressed.
    So if possible, give a guide with infographics of typical symptoms, and things to say and not say, and quick tips to help when someone has an outburst, spaces out, or gets stuck rocking, pacing, crying, or shouting in a flashback. Provide resources of how to know a friend or family member is in a flashback. It’s sometimes hard to know I’m having one and even harder for for me to communicate to others when I am stricken with confusing and sudden rage, panic, or anger. I once left my ex-boyfriend an entire voicemail of just a panic attack where I couldn’t stop hyperventilating the entire time to explain I needed immediate help.
19. On that note, consider asking your client what their flashbacks, freeze responses, etc. look and sound like so that they are able to describe the signs to your family member. Consider helping your client choose a simple way — whether it’s a hand signal or an emoticon or something else — that lets them bypass the frozen communication centers in their brain during a flashback to be a key to getting family support (e.g. hands on top of the head means dad needs a time out, don’t touch, can’t hear you; exclamation point “!” text means panic, send grounding steps please).
    Family members who don’t understand may be upset if you abruptly stop talking, don’t hear what they’re saying, leave, or smash something, and it’s really awful to be so paralyzed or possessed by an emotion that you can’t explain. Part of stabilization needs to be teaching people to teach folks in their environments to support them. These are not clients who have been taught to be good at asking for help or spelling things out for their families.
20. Keep in mind that your clients may struggle with triggering themselves with their own mannerisms, appearances, or voices similar to their parents/abusers, or from the internal parent voices in their heads. It makes sense, right? If your family has been your abusive environment where you experienced trauma, someone’s laugh, someone’s expression, or even the sound of their voice may be triggering. But what if due to family resemblance you look, sound, or act like your abuser? We end up triggering ourselves! This is very hard to deal with and can lead to us to hate aspects of ourselves. It’s worth a discussion if someone is frequently triggered and cannot figure out why.
21. Consider asking what their most common intrusive thoughts are to help develop positive internal scripts to counter them. This can be powerful. For example, some weeks I’ll hear in my head “you deserve to die” 10–20 times a day, most often when I make mistakes or fail in some way. These reflexive, negative, inner critic-style intrusive thoughts are exceedingly common to the extent that most people might not even realize to mention them. Find out what’s on loop on that record and teach clients what to say in a counter response when that happens (note: I am secure in myself and my psychiatric care. I’m sharing to show an example of the types of extreme thoughts people may consider normal).
22. Consider that the people in their lives may be truly excessive in the grandest sense, and may be completely irrational or manipulative in the majority of their behaviors. The families of folks with CPTSD often have significant intergenerational trauma that expresses in a variety of serious pathologies. This can make interactions extremely confusing for clients, especially if you predict responses or results that would be functional when you help them prepare for difficult interactions.
    Instead, ask them what has happened in the past, and when you help them change their own behavior, prepare your clients for familial escalations that you’d expect almost as if you were cutting off someone’s narcissistic supply.
    For example, one of my family members texts me 20x a day. I reply 2x a week. When I don’t reply as fast as she wants, which is most times, she group texts my friends and family members to try to shame me into replying. When I don’t take the bait, she leaves dramatic voicemails on my answering machine begging to hear my voice, or telling me she just called to hear the recording, she’s so lonely and desperate to hear from me. She has a special “sick voice” that she uses for these occasions where she aims to sound as pitiful as possible. When I tell her she’s being excessive, she’s led extensive smear campaigns against me to family members, or she will bother other relatives to the extent that they all run back, complaining to me and begging for me to give in to her so that she will leave them alone. Tactics like this can make situations seem hopeless if you haven’t prepared your client in advance for atypical behavior in the staunchest fashion.
23. Consider reading “The Body Keeps Score” to understand the physiological components of trauma, and exploring certifications in EMDR, brainspotting, sensorimotor, or somatic experiencing that have strong support for use in trauma processing.
24. Consider that your clients may not be able to handle romantic or live-in relationships because they may have such a suppressed sense of their own needs, or issues with trauma bonding/partner selection. Don’t be afraid to recommend pets (dogs, horses, cats) before relationships, or to broach the fact that intimate relationships may be triggering and too much of a challenge while folks work on themselves.
    Many people feel guilty about needing time and space for CPTSD treatment, and knowing that others struggle with it, or that it can be helpful to take time apart from serious relationships can be reassuring. (Note that roommates can also be triggering or challenging.) Many people with CPTSD have a form of hyperviligance where when anyone else is present, they feel constantly monitored or watched. Because, that’s how it was in their home growing up; any moment, someone could come yell at you for making mistakes.
25. Consider doing a parent exposure diagnostic. Many people with CPTSD need what Pete Walker calls a “parendectomy”. We get so triggered by our families that we need time off from our families, to go no contact, or move to seriously scaled down contact. Find out exactly how much exposure folks are getting early on, and consider it almost like radiation in terms of how much it will affect their mental health and wellbeing. You might be surprised how often clients are communicating with people who treat them badly, even as adults. Don’t forget that people with CPTSD may not know what normal levels of contact are, or forget about less direct modes of exposure to abusers like social media — I kept having flashbacks when I’d see my parent’s posts on Facebook, so had to take them out of my news feed.
26. Consider referring codependency or children of emotionally immature parent resources. Be sure to explain codependency and emotional immaturity in ways that are easy to understand, like, “codependency is a tendency to attend to others needs at the expense of one’s own, usually present in dysfunctional households in which people lack clear boundaries about where one person ends and the other begins.” Many children who start by having a fight or flight response, get punished at home for being unruly or running away from conflict. Freeze responses can also lead to unhappy results from angry adults. So instead they have a “fawn” response that manifests as codependent, people-pleasing behavior towards their abusers, helping anticipate and meet parental needs to avoid or prevent conflict. This might be especially common in households where parents have drug, alcohol, or mental health issues, and leads to codependent adult behaviors that do not stop without assistance. Groups like CODA and ACA can be helpful support outside of therapy.
27. Consider recommending instagram accounts, CPTSD daily supportive texts, or online/phone support groups to provide interim knowledge and resourcing between appointments — CPTSD is a lot to cope with and can feel extremely pervasive with trauma responses sometimes dominating client behavior. These are easier and more natural daily interactions for learning for people who don’t have time for books or group meetings.
28. Consider checking out the CPTSD Reddit forum (which has at time of writing, about 65k members) a few times a year to understand common themes outside your own client base, and to see what people are avoiding talking to their therapists about.
29. Consider recommending extra practices complementary to therapy like trauma sensitive yoga, somatic work, or neurofeedback. For people who seem especially scattered and ungrounded, don’t be afraid to recommend neurofeedback, which can be somewhat like EMDR on steroids for complex trauma. Yoga and other forms of breathwork can also be transformative for CPTSD clients, who tend to have trouble fulling feeling and inhabiting their bodies.
30. Clearly explain to them the stages of trauma treatment, and where they fall within that. Dealing with trauma can feel like an endless exercise…but it’s not! There are real ways to treat it in a specific program…so don’t forget to tell your clients that! It’s my understanding that standard phases include…
    Phase 1: Stabilization
    Phase 2: Trauma processing
    Phase 3: Integration
    Phase 4: Mental health maintenance, or loop backs to former phases
31. Consider clearly explaining dissociation to them. These are the symptoms that might make folks feel the most “crazy”, and be the hardest to bring up. Explain depersonalization or derealization, and talk about the potential of having different parts of self. These are not uncommon complex trauma symptoms, and clients should not be left alone to cope with them. They deserve to know that these symptoms are the result of trauma’s physiological changes in their limbic system, brain structure, and central nervous system and not any fault of their own. Please explain to them what dissociation is and how dissociative symptoms may express.
    You may need to find out where and when they experience dissociative symptoms and make plans with them — for example, dissociation while driving is common. Help a client think through whether they should pull over in instances like that.
32. Consider exploring the topic of control with them. Ask if they were controlled as a child — they may not realize this was not normal. Then, ask what they themselves controlled to feel safe. Many children avoid stepping on a crack in the sidewalk. But CPTSD clients may have had hundreds of rules (“I will always fold my sandwich wrappers into perfect hexagons”), bargains they made with God (“if I’m really good, God will keep me safe”), or other somewhat OCD type traits that made their lives feel more manageable in the worst of times growing up. Some of these fade in adulthood, and some don’t. As habits that may be 50+ years old, some clients may not even realize they are unhealthy or holding them back in some way.
33. Consider exploring their relationship with food and alcohol. Food is one of the first comforts/coping mechanisms in hard times. It is one of the easiest ways a child can self-soothe. Consequently a ton of people with CPTSD stress-eat, food binge, have textural aversions, or control the food they eat. Food may also have been a fixation of our parents in some way. Alcohol and marijuana are also negative coping mechanisms that many fall into to “numb out” of their feelings. This desire to not feel is one reason some psychiatrists do not recommend prescribing CPTSD clients benzodiazepines.
34. Consider being gentle about the way you speak about their families, as best you can.
    It’s confusing and upsetting to be told that your family isn’t healthy, that you didn’t grow up like everyone else, and that now you’re footing the bill. It can be scary to process that the people who were supposed to love you couldn’t or didn’t. Remember that as you discuss this with your clients, it may feel like they are being orphaned. They are suddenly going to have to deal with the fact that their parents (who never played the role of parents), will never really be their parents. And that’s a lot to put on someone when you tell them about intergenerational trauma.
    It’s ok to tell people their family’s behavior is unhealthy or excessive. But remember that abusive caretakers may have brought as much joy and delight as they brought terror and darkness, creating a very confusing amalgam of feelings. When the people who hurt you also gave you the best memories of your favorite childhood birthday party, for example.
    In another case, it always terrified me for my parents when fascinated psychotherapists tossed out potential diagnoses for them. Oh, they must be bipolar. But did they have BPD or HPD? Or was it bipolar schizoaffective disorder? I’d run home and read up anxiously, trying to figure out what new fears or treatments these labels might command. Because at the end of the day, they’re still my parents, and I want the best for them and the rest of my family.
35. Tell your clients up front they may feel like crap (or experience an increase in symptoms) when they go home from therapy. And help them prepare options for managing that. It can feel abrupt for those 50 minutes to be up, and then the client is on their own for a whole another week. Use the last five or ten minutes to review grounding techniques, practice sitting with emotions, or consider saying something like, “Hey, this is going to give you a lot to think about today. How will you self care later? Would you prefer to schedule a half hour of journal time when you get back in the evening, do a physical activity that helps you take out any excess adrenalin that builds up from responses you experienced in session, or schedule a call with a friend for a couple hours after therapy each week so you can distract yourself, de-intensify and re-center?” Help your clients build the habits they need to support themselves when they need it.

What did I miss? Does this sound right to you? Let me know at kathrynmintner@gmail.com and I’ll consider updating this article over time. For more information, check out my overview article and resource guide.