by Bren Michelle Chasse, Licensed Marriage and Family Therapist

Healing from Trauma Does Not Hinge on a Survivor’s Ability to Forgive

Forgiveness is an evolutionary phenomenon that, historically, has been a necessary part to building and sustaining community (Tooby & Cosmides, 2005)). In early times, it allowed groups to minimize conflict and helped support, foster, and preserve cooperation so that groups could function effectively, thrive, and achieve the goals necessary for their survival. In short, group members needed each other, a fact which didn’t change when a wrong had been done. They had to learn to deal with wrongs and stay alive. Over time, the concept of forgiveness has transformed into a modern-day virtue. Many consider forgiveness to be the moral high ground. There are even mental health providers who believe forgiveness to be the holy grail of healing, identifying it as a necessary therapeutic objective or clinical goal (Luskin, 2003). I am not one of them. 

A Deeper Look at Forgiveness and Trauma

Research has shown that, in general, people practice forgiveness more readily within their tribe or primary support group, while more likely to withhold forgiveness from those outside their group (McAuliffe & Dunham, 2016). However, this research depends on an assumption of high-functioning group dynamics. Not every relationship we experience in our lives (or even within our own family systems) falls into this category. It is simply inappropriate to generalize and apply a forgiveness model evenly across the board to all relationships. Relationships, by definition, are nuanced and very complex—and so is the experience of trauma.  

Additionally, not all transgressions are created equal. For example, I may be able to forgive a close friend who lied to me but find myself unwilling or unable to forgive the same friend if they were to assault me. A one-size-fits-all approach to healing simply doesn’t work! More specifically, the forgiveness model, when applied equally across domains, is fundamentally flawed. It fails to account for context, attachment style, cultural implications, personal moral values, organic individual differences, past experiences (including prior trauma exposure), and the depth and breadth of the transgression.  

Force-Fed Forgiveness?

Unfortunately, I’ve found in my practice that many clients have a history of being force-fed (through various sources) the value and importance of always forgiving. Consider the Lord’s Prayer, which requires we stand humbly before God and ask, “Forgive our trespasses…” and challenges us to “…forgive those that trespass against us.” The pressure to forgive is often applied by those we hold in high regard. When family members, advisors, mentors, close friends, or spiritual leaders insist on this, many clients feeling gaslit, shamed, and forced to betray themselves by placing the needs of their perpetrator above their own. 

Healing from trauma requires a focus on the self — not on the needs of another. When we claim that forgiveness is a necessary component of healing, we tell survivors that they cannot be whole again unless they extend forgiveness even to those who have committed the most physically and psychologically violent acts imaginable. 

Making Change Happen

As a society and as therapists, we must begin to change the language and conversation around forgiveness. If we don’t, we maintain the status quo and risk becoming part of the problem. The language we use, especially when we are in a position of power, really matters. 

We have to change the way we think about this topic as well. An unwillingness to forgive does not directly translate to anger, aggression, seeking revenge, or a refusal to move on, nor does it necessarily equate to a dysfunctional response to trauma. In many cases, survivors simply don’t relate to the concept of forgiveness. The healing journey focuses on creating and enforcing healthy boundaries, refusing to hold toxic secrets, learning to prioritize their own physical and emotional needs, and healing the younger parts of themselves that still feel stuck in the trauma of their past. If forgiveness isn’t part of a survivor’s healing journey, it doesn’t mean there’s something wrong. 

Be True to Yourself as You Heal

Let me be clear — for those that find forgiveness to be a healing part of your journey, I encourage you to embrace it. If you don’t relate to that, or if you feel forgiveness is a barrier to your healing, I encourage you to honor that. What I am arguing is that not everyone who experiences trauma will benefit from sharing physical, emotional, or psychological space with the person who has harmed them. Forgiveness is not necessarily a required stop along the path toward healing. Simply put, how you heal is up to you!

References

Luskin, F. (2003).  Forgive for good: A proven prescription for health and happiness. Harper One.

McAuliffe, K. & Dunham, Y. (2016). Group bias in cooperative norm enforcement. Philosophical Transactions of The Royal Society B Biological Sciences, 371(1686). doi https://doi.org/10.1111/j.1467-9221.2008.00688.x

Tooby, J. & Cosmides, L. (2005). Conceptual foundations of evolutionary psychology, in Handbook of Evolutionary Psychology, ed. Buss, D. M. Wiley, 5-67.

Understanding Intergenerational Trauma: An Introduction for Clinicians

January 8, 2021 • By Dr. Fabiana Franco, PhD, DAAETS

by Dr. Fabiana Franco, PhD, DAEETS
Simple trauma describes a single, circumscribed traumatic event (such as an assault). Complex trauma occurs when a person experiences a series of repeated traumatic events or when new, unique traumatic incidents occur such as natural disasters. Complex trauma early in life can damage multiple aspects of the child’s development. Complex trauma may involve entire families in incidents of violence, addiction, or poverty. (1)

Historical Trauma

Historical trauma refers to traumatic experiences or events that are shared by a group of people within a society, or even by an entire community, ethnic, or national group. Historical trauma meets three criteria: widespread effects, collective suffering, and malicious intent (2). Historical Trauma Response (HTR) can manifest as substance abuse, suicidal thoughts, depression, anxiety, low self-esteem, anger, violence, and difficulty in emotional regulation (3)

Intergenerational Trauma

Intergenerational trauma (sometimes referred to as trans- or multigenerational trauma) is defined as trauma that gets passed down from those who directly experience an incident to subsequent generations. Intergenerational trauma may begin with a traumatic event affecting an individual, traumatic events affecting multiple family members, or collective trauma affecting larger community, cultural, racial, ethnic, or other groups/populations (historical trauma). Those affected by intergenerational trauma might experience symptoms similar to that of post-traumatic stress disorder (PTSD), including hypervigilance, anxiety, and mood dysregulation.

Intergenerational trauma was first identified among the children of Holocaust survivors (4), but recent research has identified intergenerational trauma among other groups such as indigenous populations in North America and Australia (3)(5). In 1988, one study showed that children of Holocaust survivors were overrepresented in psychiatric referrals by 300% (6). The subjects were selected based on having at least one parent or grandparent who was a survivor.

Parenting as an Explanation for the Phenomenon of Intergenerational Trauma

While the existence of intergenerational trauma is well documented in multiple studies across several cultures, the mechanisms of transmission of intergenerational trauma remain unclear.

Trauma’s Effects on Parents

Parents may transmit inborn genetic vulnerabilities triggered by their own traumatic experience or via parenting styles that have been impacted by their trauma (7). Trauma survivors face many challenges when they are parents, including difficulty bonding to and creating healthy emotional attachments with their children. Yael Danieli categorized four adaptation styles amongst the families of survivors: Numb, Victim, Fighters, and Those Who Made It. Survivors who become numb seek silence by self-isolating, have a very low tolerance for stimulation of any kind, and are minimally involved in raising their children. Victims fear and distrust the outside world, try to remain inconspicuous, and are frequently depressed and quarrelsome. Fighters focus on succeeding at all costs and retaining an armor of strength, making them intolerant of weakness or self-pity. Those Who Made It are characterized by their pursuit of socio-economic success but also by the ways in which they intentionally distance themselves both from their experience of trauma and from other survivors (8).

Effects on Children

Children experience and understand the world primarily through direct caregivers and are, therefore, profoundly affected by their parents’ modeling. Children both mimic their parents’ behaviors and learn to navigate future relationships based on how they learned to relate to their parents. Enduring coping mechanisms due to the effects of trauma may be forged out of efforts to avoid and/or “fix” a parent’s abusive behavior, anger, depression, neglect, or other problematic behaviors.

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The Great Famine in Ukraine of 1932-1933 and Intergenerational Trauma 

The Holodomor (derived from the Ukrainian “to kill by starvation”‘) is also known as the Famine-Genocide in Ukraine, the Terror-Famine, the Great Famine, or the Ukrainian Genocide of 1932–33. It resulted from deliberate actions on the part of the authorities in Soviet Ukraine who, under the direction of Joseph Stalin, sought to force collectivization on the ethnic Ukrainian peasant population. This resulted in the deaths of millions (11).

In 2010, Brent Bezo conducted a pilot study to understand the generational impact of the Holodomor. Bezo interviewed 45 people from three generations of 15 Ukrainian families. The first generation survived through the Holodomor: the second and third generations were their children and grandchildren.

The study revealed that the coping mechanisms that the direct survivors had developed during the genocide were retained in the family system and passed down to their children and grandchildren. They described living in “survival mode,” including difficulty trusting people, a food-scarcity mentality, low self-worth, hoarding, social hostility, and risky health behaviors (10).

Aboriginal Communities in Canada and Intergenerational Trauma 

Aboriginal communities in Canada suffered from sustained trauma. For generations, Canada tried to forcibly assimilate Aboriginal people by placing them in residential schools, removing children from their families, and generally attempting to eradicate their culture and traditions (5).

The effects of this prolonged trauma have impacted First Nations groups on individual and collective levels, including markedly high rates of depression and self-destructive behaviors compared to the non-Aboriginal population. One of the challenges for mental health professionals working with community members is to understand the effects of intergenerational trauma on their clients, including a well-earned mistrust in the ministries of outsiders.

When Trauma is not Acknowledged – Learning From the Armenian Genocide

Mental health professionals are often unfamiliar with the history of those they seek to treat. Unrecognized and, therefore, unacknowledged traumatic events, such as family trauma or childhood trauma will go on to pose unique challenges for both client and clinician.

Trauma Denied

The Armenian Genocide, during which the Ottoman Turkish Empire massacred 1.5 million Armenians in 1915, is an example of historical trauma that has often been either minimized or denied outright. In fact, the mass murder of Armenians, Assyrian, Greek, and other Christian and religious minority populations of the Ottoman Empire between 1914 and 1923 has yet to be acknowledged as a genocide by the Turkish government (11). It can be especially challenging to cope with an injury while you are still fighting for its acknowledgment a century after it was inflicted. Additionally, due to this lack of formal recognition, Armenian survivors find it difficult to trust non-Armenian mental health professionals with their history and pain (12).

Coping: Family Closeness

Dagirmanjian suggested narrative therapy as a treatment with Armenians (12). Narrative therapy allows survivors to embody and settle into their perception and view of themselves (11). Another important key to working with Armenians is understanding the way Armenians value family closeness. This trait has sometimes been misunderstood and even considered unhealthy by Western clinicians who have been trained to approach family therapy with the goal of promoting individuation (12). In general, it is crucial for the mental health professional to understand the cultural context of the person suffering from trauma, including intergenerational trauma, to provide the most effective and sensitive treatment.

When Trauma Attacks the Core of a Person’s Identity 

Systematic attacks on a person or group’s identity, such as the Holocaust or the Aboriginal experience, are particularly damaging because identity and tradition are essential to perceived meaning in life. Victor Frankl, in his book, Man’s Search for Meaning, describes the imperative for people to feel securely connected to meaning in their life: without specific meaning, it is literally impossible to live (13).

In approaching survivors of historical trauma in which the intent was not only to inflict pain or kill but to demean and, ultimately, erase the identity of an entire people, the therapist must be aware that recovery requires the restoration of morale, identity, and purpose.

Culturally-Mindful Interventions

In Canada’s Aboriginal communities, intergenerational trauma treatment is complicated due to high substance use (which is itself likely a sequela of historical trauma). A valuable 2015 study (14) demonstrated the importance of blending Aboriginal and Western healing methods to treat intergenerational trauma when it was associated with substance use disorder among Aboriginal people in Canada (14). A vital element in this approach is reclaiming and recovering Aboriginal identity, including traditions, philosophies, and practices, and adapting them to current circumstances and needs. Programs that enhanced identity through cultural affiliations, increased cultural awareness through healing circles and family involvement, and were strongly influenced by traditional Aboriginal spirituality contributed significantly to decreases in substance use, domestic violence (which are often associated with substance use), and an overall increase in individual and communal healing (14).

The Role of Epigenetics in Intergenerational Transmission of Trauma 

Maternal stress and trauma are associated with health consequences for both mother and child, including low birth weight, fetal growth, and preterm delivery (15). The effect of maternal stress and trauma translate into additional risks for the infant later in life, including hypertension, heart disease, Type II diabetes mellitus, and even cancer (16).

Epigenetics refers to the study of heritable changes in gene expression in response to behavioral and environmental factors that do not change the underlying DNA sequence. In other words, epigenetics is the study of inherited changes in phenotypical properties without a difference in the inherited genetic makeup. Recent studies demonstrate that traumatic events can induce genetic changes in the parents, which may then be transmitted to their children with adverse effects (17).

In 2005, a study conducted to better understand the relationship between the PTSD symptoms of women exposed to the World Trade Center collapse on September 11, 2001, and their infant children’s cortisol levels found lower cortisol levels both in the mothers and their babies (18). Cortisol is a hormone released through the adrenal gland which helps regulate stress response. These findings speak to the importance of factoring epigenetic effects into our evolving understanding of how posttraumatic effects may be transmitted across generations (18).

Take Away Lessons for Mental Health Professionals Treating Intergenerational Trauma 

Intergenerational trauma may be transmitted through parenting behaviors, changes in gene expression, and/or other pathways that we have yet to understand fully. These may be biological, social, psychological, and/or a mixture of all three. As we trace these modes of transmission, practitioners will be better able to match interventions to specific factors that either propagate traumatic effects across generations or mitigate against their transmission. Different sources of intergenerational trauma will likely require different approaches. Innovative treatments for multigenerational trauma that borrow from indigenous cultures, acknowledge historical trauma, connect to group identity, and support survivors in finding meaning and purpose in their experience and that of their family and people are already providing practical tools for practitioners and point the way towards future progress for future generations.

References

(1) Courtois, C. A. (2008). Complex trauma, complex reactions: Assessment and treatment. Psychological Trauma: Theory, Research, Practice, and Policy, S(1), 86-100. Accessed August 24, 2017.

(2) O’Neill L, Fraser T, Kitchenham A, McDonald V (June 2018). “Hidden Burdens: a Review of Intergenerational, Historical and Complex Trauma, Implications for Indigenous Families”. Journal of Child & Adolescent Trauma. 11 (2): 173–186.

(3) Maria Yellow Horse Brave Heart “The historical trauma response among natives and its relationship to substance abuse: A Lakota illustration.” Journal of Psychoactive Drugs 35(1).

(4) Fossion P, Rejas MC, Servais L, Pelc I, Hirsch S (2003). “Family approach with grandchildren of Holocaust survivors”. American Journal of Psychotherapy. 57 (4): 519–27.

(5) Aguiar, W. & Halseth, R. (2015). Aboriginal peoples and Historic Trauma: The processes of intergenerational transmission. Prince George, BC: National Collaborating Centre for Aboriginal Health.

(6) Sigal, J. J., Dinicola, V. F., & Buonvino, M. (1988). Grandchildren of Survivors: Can Negative Effects of Prolonged Exposure to Excessive Stress be Observed Two Generations Later? The Canadian Journal of Psychiatry, 33(3), 207–212.

(7) Bowers, M. E., & Yehuda, R. (2016). Intergenerational Transmission of Stress in Humans. Neuropsychopharmacology: official publication of the American College of Neuropsychopharmacology, 41(1), 232–244.

(8) Danieli, Y. (1981). Differing adaptational styles in families of survivors of the Nazi Holocaust: Some implications for treatment. Children Today, 10: 6-10.

(9) Werth, Nicolas. 2007. “La grande famine ukrainienne de 1932–1933.” In La terreur et le désarroi: Staline et son système, edited by N. Werth. Paris. ISBN 2-262-02462-6. p. 132.

(10) DeAngelis, T. (2019, February). The legacy of trauma. Monitor on Psychology, 50(2). http://www.apa.org/monitor/2019/02/legacy-trauma

(11) Mangassarian, Selina L. (2016). 100 Years of Trauma: the Armenian Genocide and Intergenerational Cultural Trauma, Journal of Aggression, Maltreatment & Trauma, 25:4, 371-381

(12) Dagirmanjian, S. (2005). Armenian families. In G. McGoldrick & N. Garcia-Preto (Eds.), Ethnicity and family therapy (pp. 437–450). New York, NY: Guilford.

(13) Frankl, V. E. (1984). Man’s search for meaning: An introduction to logotherapy. New York: Simon & Schuster.

(14) Marsh, T.N., Coholic, D., Cote-Meek, S. et al. Blending Aboriginal and Western healing methods to treat intergenerational trauma with substance use disorder in Aboriginal peoples who live in Northeastern Ontario, Canada. Harm Reduct J 12, 14 (2015).

(15) Dunkel-Schetter, C, Wadhwa, P, & Stanton, AL. (2000). Stress and reproduction: Introduction to the special section. Health Psychol; 19(6): 507-509.

(16) Barker, D. J. P. (1998). Mothers, babies and health in later life (2nd ed,). Edinburgh: Churchill Livingstone.

(17) Yehuda R, Bierer LM (2009). The relevance of epigenetics to PTSD: implications for the DSM-V. J Trauma Stress 22: 427–434.

(18) Yehuda, Rachel, Mulherin Engel, Stephanie, Brand, Sarah R., Seckl, Jonathan, Marcus, Sue M., Berkowitz, Gertrud S., Transgenerational Effects of Posttraumatic Stress Disorder in Babies of Mothers Exposed to the World Trade Center Attacks during Pregnancy, The Journal of Clinical Endocrinology & Metabolism, Volume 90, Issue 7, 1 July 2005, Pages 4115–4118.

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© Copyright 2021 GoodTherapy.org. All rights reserved. Permission to publish granted by Dr. Fabiana Franco, PhD, DAAETS

Posttraumatic stress (PTSD) and complex posttraumatic stress (C-PTSD) are related but distinct from each other. C-PTSD is thought to be an enhanced version of PTSD. C-PTSD is, in turn, related to borderline personality (BPD).

Ongoing Interpersonal Trauma and C-PTSD

PTSD is usually caused by a single traumatic event (or a series of traumatic events) that result in a real or imagined threat to one’s life or bodily integrity. Events that could cause PTSD include exposure to war, a terrorist attack, physical or sexual assault, or even the threat of such attacks. C-PTSD is different in that it’s typically caused by ongoing trauma which is often interpersonal in nature. C-PTSD tends to be associated with continued trauma that occurs at a young age. Children who grow up in neglectful or abusive environments may go on to develop C-PTSD (Giourou et al., 2018).

Borderline Personality and Ongoing Interpersonal Trauma

Borderline personality is also connected to ongoing interpersonal trauma during childhood. Researchers have linked exposure to chronic fear and stress as a child, as well as suffering from physical, sexual, and/or emotional abuse as a child, to the development of BPD. Growing up with a parent who had a serious mental health issue is also a risk factor for the development of BPD.

BPD and C-PTSD share an association with maltreatment in childhood, and up to 71% of individuals who experience BPD report severe abuse in childhood.

BPD is a serious issue characterized by a constellation of emotional, social, cognitive, and behavioral dysregulation. The most notable features of BPD are difficulty managing emotions, impulsivity, identity problems, and dysfunctional interpersonal relationships (Hecht, Cicchetti, Rogosch, & Crick, 2014).

Common Characteristics of C-PTSD and BPD

BPD and C-PTSD share an association with maltreatment in childhood, and up to 71% of individuals who experience BPD report severe abuse in childhood. BPD and C-PTSD also share symptoms. Overlapping symptoms relate to the areas of emotion processing and regulation, security in relationships, and self-concept (Ford & Courtois, 2014).

Some common symptoms of BPD and C-PTSD include:

Emotion processing and regulation difficulties

People with BPD and C-PTSD are known to have difficulties managing and regulating emotions. When experiencing uncomfortable emotions such as anger, fear, or sadness, the person may have difficulty controlling the intensity and duration of the emotion. It can be very hard to “let things go” and return to a neutral or uplifted mood once they’ve been thrown off balance.

Relationship issues

Those with BPD and C-PTSD often have relationship issues. Relationships may be unstable, insecure, and can often be traumatic or stressful for one or both partners. We start learning how relationships work in childhood. If our caregivers in childhood were neglectful or abusive, we tend to carry these learned perceptions of ourselves, such as “I’m bad, worthless, or not worthy of support,” into our adult relationships, as well as lessons about relationships, such as “They are unpredictable, unreliable, and sometimes dangerous.”

Individuals with BPD may have an especially difficult time trusting and relating to others. It is thought that because they may not have experienced empathy from their primary caregivers during childhood, they have developed limited abilities to see past their own emotional responses and understand how others may be feeling.

Adults with C-PTSD may also have difficulty with empathy and relationships, although it depends on the nature of the trauma and whether they had access to at least one caring adult during their childhood. We are all unique, and how we develop and respond to early trauma is variable and can depend on many different factors within the environment and the individual.

Self-concept

BPD and C-PTSD are both associated with impulsive behaviors and dissociation. People may behave in ways that are self-destructive and reckless. Unsafe sex, abuse of drugs and alcohol, and disregard for one’s own safety can occur.

Dissociation is highly prevalent in BPD, and it’s known to occur in PTSD as well (Krause-Utz & Elzinga, 2018). Dissociation can result in a feeling of being disconnected from oneself and the world. Especially during times where stress levels are high, dissociation can act as a defense mechanism where the sufferer feels detached from themselves and what’s happening around them. In certain cases, amnesia may result, as well as a feeling of “lost time.” Identity confusion can also occur, and the person may feel as though they don’t have a strong sense of self or that their identity seems to shift depending on the circumstances and the environment they find themselves in.

High levels of worry, sadness, and shame

Borderline personality and C-PTSD are associated with high levels of general distress. Many feel isolated and empty, as a significant portion of their symptoms can affect their relationships and connection with others. They may have high levels of shame and sometimes experience a feeling that they have been permanently damaged. This can lead to the desire to withdraw from others, as relationships are often a source of stress, insecurity, and/or conflict.

What If You Have Symptoms of Both C-PTSD and BPD?

Complex posttraumatic stress and BPD require treatment and support. If you are experiencing symptoms of C-PTSD and BPD, it can help to first receive an accurate assessment and diagnosis. It is important to understand that nobody is permanently damaged, and there are treatment approaches that have demonstrated effectiveness for both C-PTSD and BPD.

Therapy can help you develop strategies and techniques that allow you to better cope with stress and manage difficult emotions. Ongoing support from a therapist who understands what you are experiencing and where your feelings and symptoms are coming from can be enormously helpful for your healing journey. Find a therapist near me.

If you are struggling, it is important to reach out and take advantage of the support and options available. With treatment, you can not only feel better, but also avoid the negative consequences of behavioral and emotional symptoms. Feeling better and coping with stress can improve other areas of your life as well, such as how you function in professional and personal relationships.

References:

1. Ford, J. D., & Courtois, C. A. (2014, July 9). Complex PTSD, affect dysregulation, and borderline personality disorder. Borderline Personality Disorder and Emotion Dysregulation, 1, 9. doi: 10.1186/2051-6673-1-9
2. Giourou, E., Skokou, M., Andrew, S. P., Alexopoulou, K., Gourzis, P., & Jelastopulu, E. (2018, March 22). Complex posttraumatic stress disorder: The need to consolidate a distinct clinical syndrome or to reevaluate features of psychiatric disorders following interpersonal trauma? World Journal of Psychiatry, 8(1), 12-19. doi: 10.5498/wjp.v8.i1.12
3. Hecht, K. F., Cicchetti, D., Rogosch, F. A., & Crick, N. R. (2014). Borderline personality features in childhood: The role of subtype, developmental timing, and chronicity of child maltreatment. Development and Psychopathology, 26(3), 805-815. doi: 10.1017/S0954579414000406
4. Krause-Utz, A., & Elzinga, B. (2018). Current understanding of the neural mechanisms of dissociation in borderline personality disorder. Current Behavioral Neuroscience Reports, 5(1), 113-123. doi: 10.1007/s40473-018-0146-9
5. Luyten, P., Campbell, C., & Fonagy, P. (2019, May 7). Borderline personality disorder, complex trauma, and problems with self and identity: A social‐communicative approach. Journal of Personality. Retrieved from https://onlinelibrary.wiley.com/doi/abs/10.1111/jopy.12483

Consider a person in therapy whose most evident trait is their inconsistency. From session to session, they vacillate between excitement and anxiety. One week they feel fully confident, the next, totally overwhelmed. They demonstrate or recount instances of emotional instability and mood swings, alienation and avoidance, impulsiveness and overreaction, and past trauma and continuing flashbacks.

A combination of the above symptoms could lead you to two very different diagnoses: borderline personality or complex posttraumatic stress (C-PTSD). At first glance, they share a remarkably similar list of symptoms and triggers. Their potential comorbidity (the presence of both concerns) only adds to the confusion.

However, the distinction between these two conditions is real—and often critical. Research has backed up the need to categorize them separately in the Diagnostic and Statistical Manual. The best treatment practices for addressing one condition could potentially exacerbate the other condition, should a person seeking help be misdiagnosed. It is therefore vital that practitioners are aware of the differences between BPD and C-PTSD. Therapists must also be open to revisiting their initial conclusions as therapy sessions progress.

BPD vs. C-PTSD: Understanding the Differences

The key difference between BPD and C-PTSD is that symptoms of BPD stem from an inconsistent self-concept and C-PTSD symptoms are provoked by external triggers.

A person with C-PTSD may react to or avoid potential triggers with behaviors similar to those that are symptomatic of BPD. But even if their self-representation is extremely negative, it will be consistent. This differs from the inconsistent self-representation that characterizes BPD.

It can be difficult to reach a correct diagnosis of either BPD or C-PTSD. This is because the history and self-conception of a person seeking help may take time to uncover, even if the behaviors and fluctuations common to both issues are readily apparent.

As such, treatment for BPD should focus on creating a more stable, internalized sense of self. Developing a more stable sense of self can help reduce the tendency toward self-injury and dependency upon other people.

DSM guidelines also propose a longer treatment course for BPD (at least a year), as ending therapy too soon can increase the risk of relapse due to a sense of instability or abandonment. In contrast, C-PTSD treatment aims to engage traumatic memories, foster development of a positive sense of self, reduce interpersonal avoidance, and teach resetting techniques to apply when triggers are encountered.

It can be difficult to reach a correct diagnosis of either BPD or C-PTSD. This is because the history and self-conception of a person seeking help may take time to uncover, even if the behaviors and fluctuations common to both issues are readily apparent.

Even so, most diagnoses that include BPD tend to stem from complex childhood trauma of some kind. Therapists can best support the people they are working with by determining the frequency and extent of symptoms, any potential stimuli for these symptoms, and whether symptoms can be easily regulated after being triggered.

People who are experiencing C-PTSD rather than BPD typically find it easier to overcome their emotions. If past traumas are addressed and healed, the emotional reactions that result when these memories are triggered can be lessened or subdued. People with BPD, on the other hand, often find it more difficult to calm down following intrusive memories and flashbacks. The intense emotions triggered may persist, regardless of how well the memories behind them have been engaged in therapy.

Another identifier involves looking at what is missing. Consider a person who has experienced abuse. Instability, mood changes, or re-experiences may occur in discrete instances, but if a person has no history of self-harm or fear of abandonment, a diagnosis of C-PTSD is more likely. Alternatively, when these behaviors are not always accompanied by an external trigger, or occur even when expected triggers are not present, their reactions may have been caused by internal feeling stemming from BPD.

When a person begins to notice and fear their own instability, they frequently begin to exhibit other behaviors. These might include social avoidance, alienation, hypervigilance, mood changes, and increased propensity to anger. They may describe their symptoms in terminology associated with one diagnosis or the other—for example, experiencing panic attacks (BPD) as opposed to outbursts of posttraumatic stress (C-PTSD). But clinicians need to analyze the factors above in order to accurately label and consequently treat the issues underlying the shared symptoms.

Misdiagnosis Can Affect Treatment

Focusing upon the differences between BPD, C-PTSD, and comorbid BPD and PTSD allows for distinct symptom profiles to emerge, in spite of the common symptoms that may initially be more readily apparent. These separate profiles are clinically significant, since person-centered care requires accurate identification of any and all issues experienced. This ensures that treatment methods and duration can be adapted to the specific needs of each person in therapy.

It’s important for therapists to remember that the techniques that can help people with C-PTSD reset their moods may aggravate BPD symptoms. These techniques may include reminding themselves they are safe, focusing on their present surroundings, visualizing a safe location, or moving outdoors, among others. People with BPD, who often experience apparent “overreactions” or mood swings, require acknowledgment and validation of the emotions experienced, rather than a reminder that their behavior is unnecessary or irrational.

There are effective treatments for both C-PTSD and BPD. But the best approaches for each issue differ in significant ways. Consequently, misdiagnosis can be extremely detrimental. Clinicians must therefore be prepared to weigh the differences and indicators separating the two diagnoses. It’s also important to keep in mind that it may take longer than usual to confirm or revise their initial deductions.

References:

1. Cloitre, M., Garvert, D. W., Weiss, B., Carlson, E. B., & Bryant, R. A. (2014). Distinguishing PTSD, complex PTSD, and borderline personality disorder: A latent class analysis. European Journal of Psychotraumatology, 5, 10.3402/ejpt.v5.25097. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4165723
2. Ehrenthal, J. C., Levy, K. N., Scott, L. N., & Granger, D. A. (2018). Attachment-related regulatory processes moderate the impact of adverse childhood experiences on stress reaction in borderline personality disorder. Journal of Personality Disorders, 32 (Supplement), pp. 93-114. Retrieved from https://doi.org/10.1521/pedi.2018.32.supp.93
3. Hyland, P., Ceannt, R., Daccache, F., Abou Daher, R., Sleiman, J., Gilmore, B., … Vallières, F. (2018, April 16). Are posttraumatic stress disorder (PTSD) and complex-PTSD distinguishable within a treatment-seeking sample of Syrian refugees living in Lebanon? Global Mental Health, 5, e14. Retrieved from http://doi.org/10.1017/gmh.2018.2
4. Cloitre, M., Garvert, D. W., Brewin, C. R., Bryant, R. A., & Maercker, A. (2013, May 15). Evidence for proposed ICD-11 PTSD and complex PTSD: A latent profile analysis. European Journal of Psychotraumatology, 4(1).  http://doi.org/10.3402/ejpt.v4i0.20706

Complex trauma is what happens when someone experiences multiple incidences of cruelty and abuse in the context of an unequal power relationship. This is most commonly found in people who grew up with abusive or neglectful parents, but also happens to kidnapping victims, prisoners of war, and people in abusive sexual or “romantic” relationships. The result of this complex trauma is C-PTSD (complex PTSD), which has similar effects to the posttraumatic stress (PTSD) experienced by people who have been in car accidents or similar traumatic events but involves deeper disturbances of the personality. Many people diagnosed with bipolar and other personality conditions are, in fact, survivors of complex trauma. This requires delving into the individual’s personal history and life story, rather than only analyzing their present symptoms.

Another way of looking at complex trauma and C-PTSD is the concept of attachment trauma. Attachment—the bonds that exist between one human being and another—sounds like a rather vague or abstract concept. Like all emotional states, however, such as happiness, fear, or anger, it is rooted in our biochemistry and is essential for human flourishing.

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While our level of intelligence distinguishes humans from other animals, it is only through working together that we were able to survive and thrive. There is simply no way an individual human could take down a woolly mammoth. Human beings evolved to cooperate and work together in groups. One aspect of this is our unique capacity for language acquisition. For true social cooperation, however, bare communication of information is not enough. In the modern world, one may be able to go about many items of daily business (shopping, for example) without any emotional bond, but the cohesive groups in which humans evolved required a much deeper level of connection.

Even today, we can observe that an office where there is no camaraderie between employees will not function well no matter how highly they are paid. Family life, friendship groups, and romantic relationships are, of course, quite difficult to maintain without attachment. As a result of our evolution, all, or almost all, human beings feel a deep need to be attached to others regardless of whether it is strictly necessary for their survival or material prosperity. People who do not form relationships are often plagued by feelings of depression and sadness, no matter how successful they may be in other areas of life.

Attachment, however, is hard. Forming a relationship with another human being involves both verbal and nonverbal communication, as well as an intricate dance of appropriate behavior. Express too little empathy in a relationship and you may be considered cold or distant. Express too much or too early and you may be considered overbearing. High-functioning people on the autism spectrum (commonly known as Asperger’s, though this has largely fallen out of academic usage) typically lack many of the native instincts for successful relationship formation that other people have, making their lives difficult in ways that those in the general population find hard to appreciate or understand.

However, like all human traits, the ability to form attachment bonds is not purely innate; it is learned behavior. And as with most human learning, attachment is learned by doing. From the moment they exit the womb, babies are learning attachment. This, and not only the need to materially provide for the child, is the basis of the family, a universal component of human society. Even utopian social experiments which aimed to replace the family had to fall back on structures that essentially mirrored mother- and fatherhood, with mixed success.

In treating people with C-PTSD who seek therapy, building up their ability to experience attachment and to feel safe, secure, appreciated, and loved in relationships is a high priority.

It follows, therefore, that when the relationship between parents, or a replacement primary caregiver, and the child is seriously distorted by abuse or neglect, this has far wider implications than the parent-child relationship alone. Survivors of complex trauma typically emerge with gaps in their ability to form attachment bonds with others. This is not to say their desire for attachment is any less—far from it. The unfulfilled desire for connection and pervasive feeling of loneliness in survivors of complex trauma is a major contributing factor to the symptoms they experience, including depression, inability to regulate emotion, and engagement in risky or self-destructive behaviors.

In treating people with C-PTSD who seek therapy, building up their ability to experience attachment and to feel safe, secure, appreciated, and loved in relationships is a high priority. It is also an extremely difficult process. As I have discussed in previous articles, C-PTSD is best conceptualized less as a process of damage than as a learning process in highly unfortunate circumstances. Like all children, people who grow up in an environment of persistent abuse are born with potential, which they develop in their own way under adverse circumstances.

In short, survivors of complex trauma in childhood learn to live in a world turned upside down because that was the only world they ever knew. Therapy for people with C-PTSD is a delicate undertaking, involving revisiting this initial learning process and initiating a new one that allows them to grow and develop in healthier and more fulfilling ways.

References:

1. Cloitre, M., Garvert, D. W., Weiss, B., Carlson, E. B., & Bryant, R. A. (2014). Distinguishing PTSD, complex PTSD, and borderline personality disorder: A latent class analysis. European Journal of Psychotraumatology, 5, 10.3402/ejpt.v5.25097. Retrieved from http://doi.org/10.3402/ejpt.v5.25097
2. Lawson, D.M. Treating adults with complex trauma: An evidence-based case study. (2017) Journal of Counseling and Development, 95(3), 288-298. Retrieved from http://doi.org/10.1002/jcad.12143
3. Sar, V. (2011). Developmental trauma, complex PTSD, and the current proposal of DSM-5. European Journal of Psychotraumatology, 2, 10.3402/ejpt.v2i0.5622. Retrieved from http://doi.org/10.3402/ejpt.v2i0.5622
4. Sullivan, R. M. (2012). The neurobiology of attachment to nurturing and abusive caregivers. The Hastings Law Journal, 63(6), 1553–1570.
5. Tarocchi, A., Aschieri, F., Fantini, F., & Smith, J. D. (2013). Therapeutic assessment of complex trauma: A single-case time-series study. Clinical Case Studies, 12(3), 228–245. Retrieved from http://doi.org/10.1177/1534650113479442

Working in the field of complex posttraumatic stress (C-PTSD) is immensely rewarding. Exploring a new field and finding more effective ways to help individuals in acute distress is as exciting as it is important. However, there are times when working in a developing and fertile field can also be frustrating. As a relatively new diagnosis that is still yet to be included in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5), there is a paucity of reliable evidence about many of the features of C-PTSD. One of these is the connection between C-PTSD and addiction to drugs and alcohol, as well as “lifestyle addictions” to things like sex, pornography, gambling, or shopping, to name a few.

On an anecdotal level, clinicians, including myself, have observed that people with C-PTSD often have trouble regulating and controlling their use of potentially addictive substances. Excessive alcohol or narcotic consumption is frequently one of the factors that brings people to therapy, where underlying C-PTSD is discovered. There are also good reasons, some of which I discuss in this article, to suspect a causal link between C-PTSD and addiction exists. However, without further research we cannot say with certainty what the relationship between addiction and C-PTSD is, and whether the former should be understood more as an aggravating factor or a core symptom.

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The need for further research in this area is pressing. If there is one thing we know about addiction, it is that treatment is most effective when it deals with the underlying causes. Treatment methods that address problematic drinking and drug use often have an immediate effect of allowing the person to “go clean,” only to relapse half a year later because the same factors that drove the person to alcohol or narcotics in the first place are still present. A profile of the type of addictive behavior that is likely to be an expression of C-PTSD would help addiction specialists provide targeted help and make appropriate referrals.

PTSD and Addiction

While the relationship between C-PTSD and addiction awaits adequate investigation, the link between addiction and non-complex posttraumatic stress (PTSD) is much better established. Studies have demonstrated that people with PTSD are two to four times more likely to have a substance abuse disorder compared to the general population. More than 50% of people receiving treatment for PTSD have a co-occurring issue with substance abuse. Such a strong correlation suggests a definite relationship. Three suggested mechanisms for this relationship are known, respectively, as the self-medication hypothesis, the high-risk hypothesis, and the susceptibility hypothesis.

More than 50% of people receiving treatment for PTSD have a co-occurring issue with substance abuse. Such a strong correlation suggests a definite relationship.

The high-risk hypothesis posits not that PTSD leads to substance abuse and addictive behavior, but that the two are highly correlated because they often come from the same cause. People who engage in high-risk behaviors, according to this theory, are more likely to become addicted to alcohol or narcotics and are more likely to have a traumatic experience, perhaps even as a result of being under their influence.

The susceptibility hypothesis suggests that people who have a history of alcohol or drug abuse alter their brain in such a way that they are more likely to develop PTSD. It is well known that even if two people go through near-identical experiences, one may develop PTSD while the other does not. Indeed, effective screening for PTSD after traumatic events is one of the most sought-after but elusive goals of the mental health profession. According to this theory, substance and alcohol abuse should be considered as a risk factor for PTSD.

Finally, the self-medication theory, in contrast to its two rivals, suggests the causality runs from PTSD to addiction because men and women experiencing PTSD turn to drugs or alcohol as a way of relieving their distressing symptoms. Of course, while this may work in the short term, excessive use of alcohol and other substances only serves to exacerbate the problem, because the brain adapts to these chemical stimuli and demands ever greater doses of the drug to produce ever smaller highs. In short, while the person with PTSD begins by drinking or using drugs in a hopeless attempt to briefly feel good, they end up taking them in an even more hopeless struggle to feel a little less bad.

Which of these theories may be correct has massive implications for the relationship between C-PTSD and addiction. C-PTSD is the result of prolonged, interpersonal trauma, most often experienced during childhood. If the susceptibility or high-risk hypotheses are true, we would expect there to be a lesser link between C-PTSD and addiction. While there are cases of young people falling into abusive relationships after a period of drug use, it usually works the other way around. Indeed, many people with C-PTSD began their experience of trauma as small children.

On the other hand, if the self-medication hypothesis is correct, as many professionals believe, we would expect the link to be even greater. In addition to the symptoms of PTSD, people with C-PTSD also typically have negative self-image, difficulty forming relationships, and an inability to control feelings of anger or sadness (known as affect regulation). The urge to self-medicate among people with C-PTSD would therefore be even more intense.

Of course, speculation and data are two different things. Let us hope the next few years bring to light more evidence about the nature of the connection between C-PTSD and addiction.

References:

1. Ford, J. D., & Courtois, C. A. (2014). Complex PTSD, affect dysregulation, and borderline personality disorder. Borderline Personality Disorder and Emotion Dysregulation, 1, 9.
2. Lawson, D.M. (2017). Treating adults with complex trauma: An evidence-based case study. Journal of Counseling and Development, 95(3), 288-298. Retrieved from http://doi.org/10.1002/jcad.12143
3. McCauley, J. L., Killeen, T., Gros, D. F., Brady, K. T., & Back, S. E. (2012). Posttraumatic stress disorder and co-occuring substance use disorders: advances in assessment and treatment. Clinical Psychology: A Publication of the Division of Clinical Psychology of the American Psychological Association, 19(3), 10.1111/cpsp.12006. Retrieved from http://doi.org/10.1111/cpsp.12006
4. McFarlane, A. C. (2010). The long-term costs of traumatic stress: Intertwined physical and psychological consequences. World Psychiatry, 9(1), 3–10.
5. Sar, V. (2011). Developmental trauma, complex PTSD, and the current proposal of DSM-5. European Journal of Psychotraumatology, 2, 10.3402/ejpt.v2i0.5622. Retrieved from http://doi.org/10.3402/ejpt.v2i0.5622

The condition that used to be known as “multiple personality disorder” is perhaps one of the most complex types of mental health condition. Though frequently depicted in movies and the media, since the 1994 publication of the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders, multiple personality has not been recognized as a clinical diagnosis by the American Psychological Association. In its place is the more enigmatic-sounding, lesser known “dissociative identity disorder” (DID).

Though it’s been more than twenty years since this change, a Google search of “multiple personality disorder” still produces many times the results as a search of “dissociative identity disorder.”

What, then, is the difference between the two concepts, and why hasn’t DID gained more cultural traction?

The Rise and Fall of an Idea

The idea of multiple personalities inhabiting the same body, which appears to be a constant source of fascination to the public, has long been explored in fiction, poetry, and film. Robert Louis Stevenson’s famous novel Dr. Jekyll and Mr Hyde, first published in 1886, permanently imprinted the idea of the dual personality in the collective mind long before the popularization of psychological ideas.

By 1980, when multiple personality was first identified as a separate condition, the concept of multiple personalities was already well known. Seven years previous, the book Sybil: The Story of a Woman with 16 Different Personalities, which described a woman who had 16 personalities, sold hundreds of thousands of copies and was even turned into a movie. The book’s title illustrates the way the concept of multiple personalities plays on deeply rooted concepts of possession. From 1980 to 1994, the year multiple personality was replaced with DID in the DSM, annual diagnoses went up from the low hundreds to the mid-thousands.

When psychology and popular culture intersect so neatly, there is often a danger of the latter leading the former astray, as with this case. Increasingly, professionals came to recognize that the popularized concept of multiple personalities substantially distorted the real experience of those who had been diagnosed. Thus, in the DSM-4, the diagnosis of MPD was replaced with DID to emphasize it was dissociation, rather than multiple personalities, per se, that was particularly significant.

What is different about people who have DID is the dissociation they experience when they transition between these personality states, dissociation that often leads to lapses of memory and a sense of discontinuity. In other words, what is unique is that their personality states are not integrated into a greater whole.

Increasing awareness of dissociation involves more than simply changing the name of the condition, however. To do so, I believe it is essential to consider these two key points.

First, having different personae is not what is unusual about dissociative identity. All of us are likely to behave and even think in substantially different ways depending on whether we are at work, at a party, with an old friend, a new partner, our children, and so on. What is different about people who have DID is the dissociation they experience when they transition between these personality states, dissociation that often leads to lapses of memory and a sense of discontinuity. In other words, what is unique is that their personality states are not integrated into a greater whole. As some people put it, rather than having more than one personality, they have less than one.

Another key point is that the dissociation between personality states is part of a spectrum of dissociative phenomena experienced by people who have DID. Dissociation can occur in the way the individual experiences the passage of time (i.e. flashbacks), consciousness (thinking about themselves as if they were a third or second party), their body (feeling that they are “out of body” or looking at themselves from the outside), and emotion (not experiencing normal emotions in response to stimulus or experiencing them only vicariously). In more extreme cases, dissociation might present as different personality states that may be startlingly dissimilar, but this does not mean there are actually two or more identities within the same body. Instead, DID can perhaps best be understood as a cluster of severe dissociative symptoms.

The Link Between DID and C-PTSD

As I discussed in an earlier article, dissociation is one of the most frequent and characteristic symptoms of complex posttraumatic stress (C-PTSD). Children who experience multiple incidents of abuse, neglect, or other forms of ill treatment at the hands of a caregiver may respond by detaching in some way from their situation as a coping or survival mechanism. This detachment, or pattern of dissociative thoughts, becomes a fixed part of their personality and persists into adulthood in radically changed circumstances. The stimuli triggering dissociative episodes is beyond the individual’s control and often also beyond their understanding. A central part of therapy for C-PTSD is the identification of these triggers and the development of responses that can help the individual avoid or manage dissociation.

It’s not surprising, then, that DID often co-occurs with C-PTSD. Indeed, one might go further and wonder whether the two should really be considered separate categories. Many people have criticized the “dynamic nominalism” of the DSM—in other words, the distillation of complex arrays of symptoms into concrete syndromes … until they are changed ten years later. Nothing illustrates this better than the history of DID. In the first two editions of the DSM, the phenomenon of split personalities was included as a category of what was referred to as hysterical neurosis. In the DSM-3, the terms ‘hysteria’ and ‘neurosis’ were omitted entirely and multiple personality emerged as a separate diagnosis, only until it was replaced in the DSM-4 with DID.

In this, I am reminded of the words of John Briere:

“If we could somehow end child abuse and neglect, the eight hundred pages of the Diagnostic and Statistical Manual (and the need for the easier explanations such as DSM-IV Made Easy: The Clinician’s Guide to Diagnosis) would be shrunk to a pamphlet in two generations.”

References:

1. Gillig, P. M. (2009). Dissociative identity disorder: A controversial diagnosis. Psychiatry (Edgmont), 6(3), 24–29.
2. Lanius, R. A. (2015). Trauma-related dissociation and altered states of consciousness: A call for clinical, treatment, and neuroscience research. European Journal of Psychotraumatology, 6, 10.3402/ejpt.v6.27905. http://doi.org/10.3402/ejpt.v6.27905
3. Lawson, D.M. (2017). Treating adults with complex trauma: An evidence-based case study. Journal of Counseling and Development, 95(3), 288-298. http://doi.org/10.1002/jcad.12143
4. Najavits, L., & Walsh, M. (2012). Dissociation, PTSD, and substance abuse: An empirical study. Journal of Trauma & Dissociation : The Official Journal of the International Society for the Study of Dissociation (ISSD), 13(1), 115–126. http://doi.org/10.1080/15299732.2011.608781
5. Spitzer, C., Barnow, S., Freyberger, H. J., & Grabe, H. J. (2006). Recent developments in the theory of dissociation. World Psychiatry, 5(2), 82–86.
6. Tarocchi, A., Aschieri, F., Fantini, F., & Smith, J. D. (2013). Therapeutic assessment of complex trauma: A single-case time-series study. Clinical Case Studies, 12(3), 228–245. http://doi.org/10.1177/1534650113479442