An Integrated Attachment Oriented and Cognitive Behavioral Therapy Approach to Complex Post Traumatic Stress Disorder (CPTSD)


This post reviews how an integrated Attachment and Cognitive Behavioral Therapy (CBT) approach can be used to treat common symptoms associated with Complex Post Traumatic Stress Disorder (CPTSD).  (For an overview of complex post traumatic stress disorder, please see my previous post, “An Overview of Complex Post Traumatic Stress Disorder”.  Much of the material in this post involves adaptations to CBT and an Attachment Oriented Approach based on my clinical experience.

CBT focuses on thoughts, behaviors and emotions and seeks to revise them through critical analysis and experiential exploration to be more in keeping with those that have been identified as beneficial by the client.  CBT presumes that with the assistance of a therapist, a person can effect change for the better through careful examination of their thought, feeling and behavioral habits.

An Attachment Oriented Approach involves creating a reparative relationship between the client and the therapist such that secure attachment is encouraged in the client.  The relationship with the therapist is thought to be particularly important in an Attachment Oriented Approach when dealing with CPTSD as the trauma is generally an interpersonal one.  In other words and as explained in my previous post, people suffering from CPTSD have generally been neglected, betrayed, or abused by others who are known to them and who were often in caretaker roles.  An Attachment Oriented Approach seeks to help a person develop a relationship with a therapist in which s/he feel safe, is able to identify, examine and redefine core beliefs and  explore her/himself in the world in new, freer and healthier ways.

When using these methods to treat CPTSD it is critical for the therapist to help clients to understand that symptoms and habits are adaptations and the result of traumatic experiences and not inherent character flaws.  This helps to assuage the sense of shame that is often experienced by people suffering from CPTSD.   This also helps to engender a sense of hope and empowerment that their suffering is neither inevitable nor their fault.

Some other symptoms common to CPTSD include emotional dysregulation, relational difficulties, increased sympathetic nervous system arousal, emotional flashbacks, dissociative tendencies and being harshly self critical.  Emotional dysregulation refers in part to difficulties associated with identifying, expressing, tolerating and soothing negative mood states.  These methods seek to assist clients to learn the skills noted above to regulate affect both on their own and with the help of caring and compassionate other.  Both skills are important and the capacity of a person to regulate affect inter-actively (with the assistance of another) may well be compromised as CPTSD suffers may not have had trustworthy, capable others with whom to learn this skill.

CBT is used to assist clients learn to identify what they are feeling and then to identify the thoughts associated with the feeling.  It is common for people with CPTSD to think that they are “bad” for feeling difficult feelings like sadness, grief and anger as they may not have been permitted to have such feelings by their caregivers.  CPTSD sufferers thus deny these feelings.  This leads to shame and dysregulation.  When feelings can be identified, expressed, tolerated, soothed (both through self-regulation and interpersonal regulation) and not thought of as “bad”, a person becomes more emotionally regulated.

Relational difficulties involve not being able to trust others or trusting too readily, having a hard time setting healthy boundaries, and having a so-called “insecure” attachment style. (For an explanation of insecure attachment styles please see my post on “Attachment Theory and Clinical Counselling Practice”.   Using these two methods, the therapist seeks to explore with the client their assumptions, behaviors, thoughts, feelings and history with respect to trusting others as well as whether and when they were permitted to establish boundaries in their families of origin.

Boundary work is key to healing CPTSD.  This is because sufferers have likely had many experiences of boundary violations and may not have reasonable expectations about how they should be treated.  Historical habits regarding boundary setting as well as the relational results are explored.  This exploration leads to insight and awareness and the possibility of doing things differently in the present.  Moreover, the therapist seeks to be trustworthy and to model healthy boundaries to give the client a felt experience of what it is like to safely be able to count on someone.

Clients with CPTSD have often been chronically over aroused, i.e., their sympathetic nervous systems have been on overdrive as they have had repeated experiences of not being safe.  Sometimes the state of nervous system over arousal, can become so habitual that it becomes a trait.  Therapy for CPTSD thus involves teaching clients to identify and manage nervous system over arousal.  This typically involves breathing exercises to stimulate the para sympathetic branch of the nervous system which is the relax response and can be thought of as the brakes on the sympathetic branch of the nervous system.  In addition, clients with CPTSD often over use certain strategies (to the exclusion of other more adaptive strategies) related to the fight/flight/freeze/fawn response.  It is important to help clients gain insight into these habitual behaviors and to expand their repertoire of strategies related to managing threat.

CPTSD sufferers often experience emotional flashbacks.  This is when something in the present triggers memories from the past such that a person experiences feeling states from the past which may be out of proportion or incongruous to the present.  When in the midst of an emotional flashback a person often feels small, helpless, hopeless worthless and utterly overwhelmed.  (For a thorough explanation of how to soothe emotional flashbacks, please see my post on CPTSD and emotional flashbacks.)  CBT methods help a person use their thoughts to recognize that they are actually in the present and not in the past, that they have far more resources at their disposal than they did when the original trauma(s) occurred and that they are actually lovable despite not having been well treated historically.

When CPTSD sufferers are emotionally over whelmed it is not uncommon for them to dissociate.  This involves “splitting off” and “compartmentalizing” feelings and awareness of the events that precipitated them, as these things are too upsetting to integrate into ordinary consciousness.  Attachment Oriented methods encourage the acceptance, exploration and integration of upsetting feelings and experiences by allowing them to be processed with a skilled other with whom the client feels safe enough to tolerate that which was historically off limits.

Children who are neglected or abused can’t fathom that their caregivers are inadequate, neglectful or abusive.  They are utterly dependent and have no choice but to adapt to their circumstances.  They believe that they must deserve the treatment that they are receiving.  It is common for the children who become adults with CPTSD to try to be perfect to get the love and nurturing that they crave from their caregivers.  As part of this process, they internalize the messages that they get from their caregivers and become harshly critical of themselves.  CBT aims to identify and revise these self criticisms and negative core beliefs through various methods including “thought substitution”.  Attachment Oriented methods encourage the capacity to be loving and compassionate to oneself.

If you believe you may be suffering from CPTSD and would like assistance, please feel free to fill out the contact form below.

An Integrated Approach to Complex Post Traumatic Stress Disorder (CPTSD)