"Enhancing The Quality Of Relationships Between People"
a) models of simple PTSD and how multiple trauma complicates
presentation (memory models)
b) explaining the impact of developmental trauma
c) explaining windows of tolerance (level of arousal tolerable to client)
d) explaining dissociation
e) explaining symptoms and emotional responses
Psychoeducation for CPTSD usually features an explanation of PTSD, including
the reason for intrusive symptoms and justification for exposure work, as well as
an explanation of symptoms and skills-deficits. This aims to increase the
individual’s understanding of the difficulties, commitment to therapy and selfcompassion,
and reduce shame. Frequently covered topics are summarised
a) Models of PTSD
The three main models used to explain PTSD are:
Ehlers and Clark cognitive model
Brewin’s dual representation theory of PTSD
Foa’s fear network.
According to the Ehlers and Clark cognitive model (Ehlers and Clark, 2000),
PTSD becomes persistent when, in processing the traumatic event and/or its
sequelae, the individual perceives a continuous sense of serious current threat.
Two key processes are implicated:
negative appraisals of the trauma and its sequelae
disturbance of autobiographical memory, characterised by strong
perceptual memories (such as intrusive images and emotions) that are
disconnected from their context and an intellectual understanding of the
This leads to behavioural and cognitive responses and strategies (e.g.
avoidance) designed to reduce the perceived level of threat and associated
distress. Although effective in the short term, these strategies prevent cognitive
change in the longer term and hence maintain post-traumatic stress.
Brewin’s dual representation theory of PTSD (Brewin et al., 1996; Brewin
and Saunders, 2001; updated in Brewin, 2011) describes two components of
memory representations: sensation-based (S-rep) and contextual (C-rep).
In healthy memory, the two components are paired and form the ‘hot’ and ‘cold’
parts of the memory respectively. Under extreme stress the hippocampus
becomes significantly less active and the amygdala significantly more active.
Under these conditions the C-rep is weakened and, rarely, can be absent at the
most traumatic moment of a memory. This means that the S-rep loses its
context (so is not integrated with time, place and surrounding knowledge) and
can only be retrieved involuntarily, and is associated with a much more powerful
autonomic response. These are experienced in PTSD as flashbacks.
Foa’s fear network (Foa et al., 1992) proposes that trauma forms a fear
network in long-term memory, which is activated by trauma-related cues.
Information from the network enters the consciousness and leads to intrusions
and attempts to avoid and suppress memories. Successful resolution of the
trauma requires integration of the fear network and existing memory structures.
However, this is challenged by the unpredictable and uncontrollable nature of
trauma; disruption of cognitive processes of attention and memory at the time
of trauma; and the creation of a disjointed and fragmented fear network.
The Ehlers and Clark (2000) model is easily explained to clients and offers a
helpful way to illustrate the need for an exposure-based intervention and
tackling behavioural avoidance. It is commonly used to guide formulation in
people with PTSD. Brewin’s model has neuropsychological support and is useful
as a rationale for the usefulness of imagery and nightmare rescripting, while
Foa’s model is a useful way of explaining the impact of multiple trauma and as a
rationale for treatment. It is an important part of psychoeducation for narrative
exposure therapy (NET) and can also be useful in introducing eye movement
desensitisation and reprocessing (EMDR) therapy. Nevertheless, it is important
to note that all these theoretical conceptualisations have been developed
primarily to explain PTSD rather than CPTSD.
Models of PTSD can often be introduced to clients using metaphors or simple
diagrams. Common metaphors include the image of a linen cupboard, a filing
cabinet or a photo album. Some clients find these metaphors helpful, while
others prefer a simple explanation1 of how memories are stored in the brain.
b) Explaining CPTSD including developmental trauma
Attachment theory forms a useful basis for explanations of developmental
trauma and some clients may benefit from reading about this. The foundations
for difficulties in recognising and regulating affect can be explained through
attachment and reciprocity. A parent/carer’s ability to resonate with an infant’s
internal states, and translate them into actions and words appropriate to the
child’s stage of development, will eventually lead to the child’s ability to connect
internal states with words. Mother-infant synchrony contributes to the
organisation and integration of neural networks and the development of selfregulation.
At times of threat or distress our attachment system is activated and
we revert to our underlying internal working models. If these are organised and
stable, thanks to reliable and consistent carer response to infant distress, the
individual will be able to regulate their emotional experiences in adulthood.
Where this is not the case, the individual will have difficulty identifying and
safely regulating their emotions, and will be more likely to find them
c) Explaining windows of tolerance
A person’s window of tolerance (Ogden et al., 2006) is sculpted by their early
attachment relationships. Auto-regulation is the ability to calm oneself when
arousal rises (sympathetic activation) to the upper limits of the window of
tolerance or to increase activity when arousal drops (parasympathetic
activation). Many people with CPTSD show affect intolerance in response to
under- or over-activity of the stress response system. Such inability to tolerate
intense emotion may result in, for example, addictive behaviour, self-harm (to
1 See for example:
discharge emotion), or dissociation. Alternatively, an individual may experience
on-going low activation, such that they spend considerable periods in a numb,
inert, or disengaged state.
A person’s window of tolerance narrows as a consequence of repeated trauma
and influences, resulting in:
reduced emotion regulation abilities
reduced relational capacities
reduced capacity for attention and consciousness
negative influence on belief systems
increased somatic distress or disorganisation.
Treatment of CPTSD builds emotional resilience and integrative capacity, which
can only happen with an increased window of tolerance.
d) Explaining dissociation
Dissociation is defined in DSM-5 (2013) as ‘disruption in the usually integrated
functions of consciousness, memory, identity or perception of the environment’.
Some people dissociate during trauma (Holmes et al., 2005; Murray et al.,
2002; Ozer et al., 2003). Such peritraumatic dissociation may be experienced as
spontaneously ‘going blank’, ‘switching off’ or ‘leaving’ their body (derealisation
or depersonalisation), and may be an attempt by the individual to distance
themselves from the distress they are feeling. Consequently, the traumatic
memory, or parts of the memory, can become inaccessible to conscious
awareness (Wright et al., 2006). The encoding of the memory can become
altered by traumatic experiences resulting in fragmented yet vivid sensoryperceptual
memories or ‘flashbacks’ (Grey and Holmes, 2008). Recalling
traumatic events might then trigger dissociation.
Even when there is no peritraumatic dissociation, recall of traumatic memories
can result in a parasympathetic response that makes dissociation likely (Schauer
et al., 2011).
The theory of structural dissociation of the personality postulates that the
personality of traumatised individuals is unduly divided into two basic types of
dissociative subsystems or parts (Nijenhuis et al., 2010). One type (referred to
as the Apparently Normal Part/s) primarily functions in line with the individual’s
daily life goals; the other type (Emotional Parts) are dissociative parts, fixated in
the trauma and primarily serving a defensive function. The more severe and
chronic the traumatisation, the more dissociative parts are likely to exist.
Helping clients to understand why they may have developed different parts as a
means of coping with repeated trauma may serve to increase understanding of
the disintegration often experienced in CPTSD. This model may also offer an
integrated formulation of the multiple diagnoses that many people with CPTSD
People with CPTSD often present with a wide range of symptoms associated with
their attempts to manage the emotional distress linked to trauma, resulting in
multiple diagnoses to account for these symptoms. For this reason, it is essential
that an individualised formulation is developed that brings together the range of
symptoms and difficulties experienced by the individual.