“Complex” PTSD is well recognized in clinical circles, despite the APA’s refusal to acknowledge it in the DSM-5. This unofficial diagnostic category represented a dramatic shift in our understanding of trauma. It led us to a more compassionate understanding of symptoms that were once dismissed as attempts at manipulation. Even in the early days of my career, some colleagues discouraged me from paying too much attention to clients who engaged in self-harm or expressed recurrent suicidal thoughts. Why? Because there was still the belief that they were just “doing it for attention.” This was a mere 10 years ago. This is an exciting time to be a therapist, when our understanding of trauma is evolving at a rapid pace.

As a general rule, most human beings have a natural biological drive toward health. Self-destructive behavior defies the fundamentally sacred instinct that allows us to grow and evolve as a species. So, why would anybody harm themselves, through self-mutilation, substance abuse or any other high-risk behavior?

The answer: It is precisely because of our fundamental desire to survive that we will employ any and all means to avoid things that feel like death.

For those who do not have complex PTSD, most normal life stressors do not feel like impending doom. Such people have well-regulated nervous systems and a capacity to calm themselves down. They can accept criticism, make mistakes, handle rejection and weather emotional storms that naturally arise from being alive. When you suffer from complex trauma, the emotional reaction to such circumstances is so intense that you may experience emotional shutdown, AKA, dissociation, sometimes manifesting as depersonalization, derealization and a general sense of either feeling like you do not want to exist or already DON’T exist as a real person. In some circumstances, external means of self-soothing must be employed to return to a state of equilibrium. Those who have learned DBT skills or similar interventions may have developed safe ways to calm themselves down. Those who have not learned such skills may resort to behaviors that are a serious threat to themselves or others.

I’ve got two things to say to people who struggle with these compulsions: It’s not your fault, and it does get better.

Complex PTSD does not result from a single traumatic incident. It results from chronic and prolonged exposure to situations perceived as life-threatening. It is impossible for a person to learn how to calm themselves down if they have lived in a world that is never safe. Why calm down? Another threat is just around the corner. In many (if not most) circumstances, the trauma occurred in early childhood, when the vulnerable nervous system was still developing. In cases like this, the nervous system learns to stay in a state of constant agitation and/or shutdown. Many SE practitioners describe this as living with the brakes on and the gas pedal floored at the same time.

I’ll say it again, in case you need to hear it:  It’s not your fault. Congratulations on staying alive. You’re stronger than you think, and the world is better for having you in it.

With regards to “it gets better”, here’s how it happens:

You find a small island of safety. Here’s the trick…it has to be an island that you create for yourself. If it’s conditional on another person constantly being around, it’s not going to feel stable. No matter how much you love someone, or how much they love you, nobody can be around 100% of the time. Actually, your loved ones will be better support people for you if they take time for themselves. So, let your island be something you can control.

No matter how small that island is, let yourself trust it, and enjoy it completely. Five minutes of fresh air? One chapter of a good book? Great. Stop thinking about how it won’t last. Yes, I know it’s hard. Stop, or at least notice the gaps between worrying. I guarantee they are there. Let yourself sink into that island. Watch it grow. The more you attend to that place and nurture it, the larger it will get. I promise.

As you notice what it’s like to feel pleasure, tell yourself that you deserve pleasure. I know, I know…this is hard too. You may need to hear it from a therapist on repeated occasions. Eventually, though, you will find that you start treating yourself like a human being. This leads to the belief that you deserve to be treated like a human being by others around you.

You start to set boundaries. Toxic relationships either become less toxic or fall by the wayside. The friends who matter stick around. New friends come in as you feel more comfortable reaching you to people who are good for you. Your support system widens, and your relationships deepen. You no longer feel like somebody who is constantly in need of help, but you know how to ask for help without feeling ashamed.

This all takes time, and patience with yourself. Therapy will initially focus on getting the self-destructive behaviors under control. DBT or recovery groups may be recommended in addition to individual therapy, if the behaviors are severe. Working on the actual trauma will happen once safety is established. Therapeutic progress is often measured in years, rather than weeks or months. Medication may be necessary, at least on a temporary basis. There will be setbacks. There will be plenty of opportunities to forgive yourself, and learn what it’s like to deserve forgiveness. That, in and of itself, can be a healing experience.

I have one last bit of good news: you made it through this entire article. That probably means you have a sense that some if it is true…and that you can make it. All of the work mentioned above is a lot of work, but you probably have a sense that life is worth it. Otherwise, you wouldn’t be looking up therapists and thinking about getting help.

Congratulations on taking the first step. You can do it.