Overview
Complex or developmental trauma may present less as a coherent account of frightening events than as a persistent way of experiencing oneself and other people: “I am defective,” “Other people will hurt or reject me,” or “It is unsafe to need anyone.” Some patients present with nightmares and hypervigilance; others with self-criticism, numbness, anger, shame, withdrawal, self-harm, or apparent compliance. This guide addresses three clinical tasks: recognizing these overt and subtle presentations without presuming a trauma history; conducting assessment and treatment in ways that preserve safety, agency, and trust; and using psychodynamic interventions, especially holding, containment, and attention to selfobject needs, with appropriate restraint.
The following is synthesis of three key articles Maercker et al. (2022), Sweeney et al. (2018), and Alessi and Kahn (2019).
Reference of this introduction:
OpenAI. (2026). Complex and developmental trauma in psychodynamic psychotherapy [Educational guide generated by ChatGPT, GPT-6; prompts written and results were reviewed by Joachim Sehrbrock, PhD].
1. Recognizing and assessing complex and developmental trauma
Start with three distinctions
• Traumatic exposure is not a diagnosis. Experiences of extreme threat or horror are risk factors, not guarantees of PTSD or complex PTSD. Sustained childhood abuse and prolonged interpersonal violence are particularly associated with complex PTSD, but some exposed individuals develop PTSD alone or neither disorder; complex PTSD may also follow a single severe event (Maercker et al., 2022).
• Developmental trauma is a formulation, not interchangeable with ICD-11 complex PTSD. The expression “developmental trauma” foregrounds the timing and cumulative developmental consequences of adversity, including maltreatment and neglect. “Complex PTSD” (ICD-11 code 6B41) is a defined syndrome. A patient can have clinically consequential adversity and relational adaptations without meeting its full criteria. Sweeney et al. (2018) also use a broader social and psychological conception of trauma; this must not be confused with diagnostic thresholds.
• Trauma-informed care is not necessarily trauma-focused treatment. The former is a framework for how to relate, assess, collaborate, and avoid preventable harm; the latter directly targets trauma-related psychopathology, potentially including trauma-memory work (Alessi & Kahn, 2019; Sweeney et al., 2018).
The six ICD-11 complex PTSD symptom clusters
For ICD-11 complex PTSD, assess exposure to an extremely threatening or horrific event or series of events; at least one symptom in each of three core PTSD clusters and each of three “disturbances in self-organisation” (DSO) clusters; and substantial functional impairment. The three PTSD clusters are (1) re-experiencing the event in the present, (2) avoidance of reminders, and (3) a persistent sense of current threat. The DSO clusters are (4) affect dysregulation, (5) a persistent negative self-concept, and (6) relational disturbance (Maercker et al., 2022).
• Re-experiencing in the present. Flashbacks or nightmares experienced as if danger were current, not just ordinary autobiographical remembering. The patient may be pulled suddenly into fear or helplessness by an image, sensation, place, smell, or interpersonal cue.
• Avoidance. Avoiding conversations, memories, people, places, sensations, or emotional states that evoke the event. Absence of spontaneous disclosure does not imply absence of trauma.
• Persistent current threat. Hypervigilance, exaggerated startle, and the felt anticipation that danger can return. Ordinary interactions can be experienced through an expectation of threat.
• Affect dysregulation. Not only overwhelming fear, anger, or rapid escalation but also detachment, shutdown, emotional numbing, or difficulty knowing what one feels. A patient may seem dramatically distressed, strangely calm, or alternate between the two.
• Negative self-concept. A pervasive, enduring sense of being bad, worthless, defeated, unlovable, damaged, or responsible for what happened. This is more than feeling guilty about a particular act; it can feel like a fact about one’s identity.
• Disturbed relationships. Persistent difficulty sustaining closeness, trust, or a felt connection. Patients may withdraw as intimacy develops, anticipate exploitation or rejection, or perceive themselves as fundamentally apart from others.
The DSO phenomena are especially significant because, unlike event-linked PTSD reactions, they can be pervasive across situations and may be experienced as personality or identity rather than as “symptoms.” The three source articles illustrate these features clinically, but no single behaviour or interpersonal style is specific to complex PTSD.
What it may feel like from the inside: subtle clinical presentations
The following are phenomenological translations of patterns described in the articles, not quotations from patients or independent diagnostic criteria. They can guide empathic inquiry and formulation, not replace it.
• Self-criticism and shame. “I should have known better”; “If I had been stronger this would not have happened”; “Something is wrong with me.” Maercker et al. describe patients who construe prolonged exposure to harmful environments as normal and conclude that their suffering reflects an inborn defect. In Alessi and Kahn’s case illustration, humiliating parental messages are echoed in the patient’s self-appraisal and tolerance of criticism from partners.
• Safety through appeasement or overcompliance. “It is easier to agree”; “If I disappoint you, something bad will happen.” Sweeney et al. identify overcompliance and quiet distress, as well as anger and withdrawal, as possible coping adaptations. In treatment, this may look like an agreeable patient who cannot voice discomfort or disagree with a therapist.
• Shame-driven distance from relationships. “If you knew what happened to me, you would think less of me”; “Getting close makes me vulnerable.” In a case reviewed by Maercker et al., closeness prompts ending relationships for fear of disclosing an assault history. Apparent detachment may conceal longing and fear, rather than an absence of attachment needs.
• Irritability and perceived criticism. A minor frustration may elicit rapid anger or alarm. The patient may scan comments, silence, or changes of tone for signs of rejection, control, or impending attack. This is clinically relevant to the therapy relationship but not proof of trauma.
• Numbing, dissociation, and disconnection. “I go blank”; “I lose track of time”; “I don’t feel anything.” Maercker et al. discuss dissociation as common and important to assess, although not itself one of the six essential ICD-11 CPTSD clusters. Sweeney et al. also describe freeze, apathy, and disengagement as potential adaptive responses.
• Self-destructive ways of obtaining relief. Substance use, self-injury, risky behaviour, or disordered eating may temporarily contain unbearable shame, arousal, or disconnection. Sweeney et al. encourage understanding coping and communicative functions while still addressing the real danger of these behaviours.
• Loss of hope or presumed permanence. “I have always been this way”; “I am beyond repair.” Such statements may signal chronic negative self-organization as much as depressive symptoms, though depression and other disorders must be assessed independently.
• Misreading help as judgment or control. Advice, questions, reassurance, or silence may be received as evidence that the therapist regards the patient as incompetent or unworthy, or will ultimately abandon them. This is a possible relational hypothesis, not something to presume or confront as fact.
Assessment: establish syndrome, meaning, context, and alternatives
A trauma history is part of a broad biopsychosocial assessment, not a demand for a detailed narrative. Sweeney et al. recommend normalizing questions, using clear examples, and allowing patients to decline. Maercker et al. recommend concentrating initial inquiry on effects of trauma rather than collecting an exhaustive account. A clinically manageable sequence follows.
• 1. Explain and ask permission. Indicate that difficult experiences can affect mood, sleep, self-perception, and relationships; explain why you ask and explicitly allow a “not now.” Avoid inquiry during acute crisis when immediate stabilization is necessary.
• 2. Enquire broadly, then specifically. Ask about childhood safety and caregiving, harsh punishment, sexual coercion or abuse, interpersonal and community violence, and ongoing threat. Explore structural and cultural conditions, including discrimination and marginalization, without automatically classifying every adversity as an ICD-11 qualifying event.
• 3. Ask first about the impact and the present. Consider “How have these experiences affected the way you see yourself or relate to other people?”; “What situations make you feel unsafe now?”; “When feelings become intense, what happens?” Avoid requiring a detailed chronological retelling for screening.
• 4. Assess all six CPTSD clusters and functional impairment. Ask directly about present-tense re-experiencing, avoidance, threat, hyper- and hypoarousal, persistent worthlessness or shame, relationship withdrawal, and consequences at work, home, and socially. The International Trauma Questionnaire (ITQ) is a widely studied ICD-11 self-report instrument; the clinician-administered International Trauma Interview (ITI) was less extensively validated at the time of Maercker et al.’s review.
• 5. Assess risk and comorbidity. Enquire about active violence, suicidality, self-harm, dissociation, substance use, depression, anxiety, somatic problems, and possible psychotic-like phenomena; identify housing, medical, and social support needs. Address urgent safety and social needs alongside diagnostic formulation.
• 6. Differentiate rather than collapse diagnoses. CPTSD and PTSD are mutually exclusive within ICD-11: CPTSD includes the PTSD triad plus DSO. CPTSD and borderline personality disorder overlap but are not synonymous; Maercker et al. describe more consistently negative self-evaluation and interpersonal withdrawal in CPTSD, versus more unstable self-image and volatile relational engagement often seen in BPD. These are patterns, not absolute rules, and co-occurrence or alternate diagnoses require full evaluation. The DSM-5 framework discussed by the authors did not include a separate CPTSD diagnosis.
• 7. End with regulation, resources, and follow-up. Check current distress and safety, clarify confidentiality and its limits, identify sources of support, and explain what happens next. Assessment should not leave the patient newly distressed and unsupported.
Diagnostic discipline: Self-criticism, perfectionism, people-pleasing, anger, mistrust, intellectualization, or numbness cannot establish a trauma history, causation, or CPTSD diagnosis. The clinician must preserve alternative explanations and allow the patient to describe what is meaningful to them. Conversely, a patient who does not meet CPTSD criteria may still benefit from a trauma-informed therapeutic stance.
2. Trauma-informed principles in assessment and ongoing psychodynamic therapy
Sweeney et al. (2018) describe ten linked principles: seeing through a trauma lens; acknowledging less visible social and cultural trauma; sensitive discussions of trauma; access to trauma-specific support; preventing retraumatization in services; trustworthiness and transparency; collaboration and mutuality; empowerment, choice, and control; safety; and survivor partnerships. The principles are not a manual of discrete evidence-proven techniques, but an organizing stance. Alessi and Kahn (2019) connect this stance to the everyday psychodynamic therapeutic relationship.
Make safety observable, not merely asserted
• Predictability and clarity. Explain the treatment frame, confidentiality and its limits, fees and cancellation arrangements, what assessment or treatment may involve, and the purpose of a particular intervention. Be consistent and explain changes. Do not assume the therapist’s benevolent intentions automatically create felt safety.
• Relational safety. Respond respectfully to shame, silence, withdrawal, anger, and uncertainty; demonstrate that negative affect and disagreement can be heard without retaliation or humiliation. A stable frame and an emotionally available therapist make exploration more possible.
• Internal safety. Notice whether the patient can think and remain connected while distressed. When affect becomes disorganizing, prioritize containment, orientation, and workable ways of regulating. Avoid making emotional intensity an end in itself.
• Actual external safety. Where there is ongoing violence, coercion, insecure housing, or acute self-harm risk, formulation alone is insufficient. Practical safety planning and referral to appropriate supports may be necessary before, or alongside, deeper work.
Protect agency and preserve collaboration
• Ask rather than extract. Invite trauma histories as clinically relevant but give meaningful permission to defer, decline, or redirect. The absence of disclosure is not an invitation to probe more forcefully.
• Make disagreement possible. Check whether the formulation resonates; ask what feels mistaken or unhelpful. A patient who agrees quickly may still feel unsafe disagreeing. Monitor whether the treatment relationship creates rather than reduces passivity.
• Share the rationale. Explain why you are asking about affect, noticing a relational pattern, or revisiting a topic. Collaboratively prioritize current symptoms, relational functioning, safety, and trauma-specific treatment needs.
• See adaptive functions. Consider what apparent “resistance,” angry withdrawal, compliance, self-injury, or substance use might accomplish in the moment. Understanding is not endorsement, and the patient may also need help changing dangerous or disabling patterns.
• Attend to difference and social context. Avoid reducing actual racism, sexism, homophobia, poverty, or ongoing coercion to intrapsychic distortion. Explore identities, power asymmetries, and meanings without expecting the patient to educate the therapist or reveal painful material.
Prevent subtle relational reenactments and respond to disruptions
Retraumatization is not synonymous with any difficult feeling in psychotherapy. Sweeney et al. particularly emphasize experiences that recreate helplessness, violation, objectification, and coercive “power-over” relationships. In outpatient psychotherapy, analogues may include a therapist dismissing the patient’s meaning-making, pressing for disclosure after refusal, overriding an expressed concern, or responding defensively to criticism. These examples are clinical applications of the source principles, not experimentally established triggers in every patient.
• Notice the interpersonal effect of your intervention. An accurate interpretation can still be experienced as invasive, shaming, or controlling. Ask what the patient felt on hearing it, rather than immediately defending its correctness.
• Repair misunderstandings and ruptures. Acknowledge the impact of a misattuned question or tone; explore what occurred together without insisting the patient accept the therapist’s account. Transparency and sincere attention support trust.
• Use supervision for the therapist’s experience. Notice helplessness, fear, anger, urgency to rescue, excessive reassurance, or a wish to retreat from strong affect. Alessi and Kahn conceptualize countertransference as potentially informative, but it requires reflection before it becomes intervention.
3. Psychodynamic clinical implications: techniques, timing, and cautions
Alessi and Kahn (2019) propose three complementary psychodynamic processes: a holding environment supports relational safety; containment supports internal safety; and attention to selfobject transferences supports self-cohesion and relatedness. These are meaningful clinical formulations, not independently proven mechanisms of CPTSD treatment. Maercker et al. (2022) report stronger direct outcome evidence for evidence-based trauma-focused and multicomponent treatments, while noting that specific psychodynamic and attachment-based components remain insufficiently studied for ICD-11 CPTSD.
A. Establish a holding environment before demanding insight
“Holding,” drawn from Winnicott’s object relations theory, concerns the reliable psychological and practical frame within which feelings can be experienced without expecting abandonment, humiliation, or coercion. It is not unlimited reassurance or absence of boundaries. It involves predictable scheduling and limits, steady emotional availability, and an openness to the patient’s pace and cultural context.
• Therapeutic move. When a patient hesitates to disclose an experience, say, “We can understand what is affecting you without going into details before you are ready.” Respect the decision while remaining curious about its subjective meaning if the patient wishes to explore it.
• Dynamic focus. Over time, explore how expectations of criticism, abandonment, or intrusion may appear with the therapist. A tentative here-and-now observation might be: “I wonder whether my question sounded as though I expected an answer you were not ready to give.”
• Caution. Do not equate waiting with passivity forever, or assume that a patient’s alarm necessarily reflects transference rather than something about the therapist’s actual behaviour. Do not rush to interpret withholding as resistance.
B. Containment: help the patient think about affect rather than merely endure it
“Containment,” drawing on Bion, involves receiving strong or unformulated affect, reflecting upon it, and returning it in a more thinkable form. Alessi and Kahn distinguish it from holding: the first provides an interpersonal frame; the second helps make intense internal experience more tolerable. Containment might involve naming an affect, slowing the pace, linking an overwhelming reaction to meaning, and monitoring one’s own countertransference.
• Therapeutic move. “As you describe that interaction, it seems both frightening and humiliating, and it may be difficult to know which feeling is strongest.” Then leave room for correction rather than assuming the label is right.
• Dynamic focus. Explore a sequence: precipitating event, felt affect or bodily signal, feared relational consequence, defensive response, and short-term protective function. For example: criticism → shame and danger → withdrawal or anger → reduced exposure but greater isolation.
• Caution. An interpretation that intensifies affect faster than the patient can think about it may fail to contain. Conversely, reflexively soothing or changing the subject can foreclose exploration. Calibrate to the patient’s capacity in the moment; the source articles do not establish a universal required sequence of stabilization before trauma work.
C. Work with selfobject needs and injuries to the sense of self
Alessi and Kahn use Kohutian self psychology to describe three relational needs, especially pertinent when patients feel chronically unseen, unsafe, or alien: mirroring (one’s experience recognized and validated), idealizing (access to another’s felt steadiness and strength), and twinship (a sense of human likeness and belonging). Their article explicitly notes a lack of empirical studies testing self psychology as a trauma treatment. Use these as possible lenses on the relationship, not as diagnoses.
• Mirroring. Recognize the subjective experience before challenging assumptions or offering solutions. For example: “Having to ask for that was vulnerable, and being refused felt crushing.” This does not require agreeing with every factual claim or avoiding thoughtful questioning later.
• Idealizing. The patient may need to experience the therapist as consistent and calm before being able to rely more on their own capacities. Receive appreciation without exploiting dependency, encouraging idealization, or implying the therapist is invulnerable.
• Twinship. Convey that distress does not remove a person from ordinary human belonging. Attuned normalization can counter isolation. Limited self-disclosure might sometimes serve a thoughtful relational purpose, as in Alessi and Kahn’s vignette, but disclosure should be evaluated for its usefulness to this patient, not to relieve therapist discomfort.
• Caution. Do not impose a selfobject interpretation, offer indiscriminate praise, or prematurely dismantle a needed experience of steadiness. Strong affirmations may themselves be mistrusted or experienced as intrusive.
D. Interpret defenses and transference as possible adaptations, without presuming their origins
Contemporary psychodynamic work attends to recurrent patterns, affect, wishes, internalized interpersonal expectations, and the therapy relationship. The trauma-informed addition is a disciplined question: what protective function might this pattern have acquired, and what does it cost now? Alessi and Kahn’s vignette shows a patient who accepted belittlement by a partner against a background of childhood humiliation and feared eventual rejection by the therapist. It is a case illustration, not proof that similar patterns always have this developmental origin.
• Begin with description and curiosity. “I notice that when the conversation turns toward what you need, you quickly start explaining the other person’s perspective. What is it like to stay with your own reaction for a moment?”
• Link present and past tentatively. “I wonder whether being criticized now carries some of the same feeling of being put down that you described from childhood. Does that fit, or is it different?”
• Explore transference without insisting. “When I asked why you missed last week, did it feel as though I was blaming you?” Allow the patient to tell you how the therapist was actually experienced, including ways the therapist may have contributed.
• Hold conflict and agency together. A protective adaptation may have been essential earlier and restrictive now. Explore both the value of the defense and possible alternatives, rather than equating change with getting rid of an irrational symptom.
• Caution. Avoid early, authoritative interpretations of a patient’s trauma, sexuality, aggression, dependency, or presumed unconscious motives. Do not reinterpret credible reports of current mistreatment as mere projection. Do not treat every clinical disagreement or silence as trauma-derived.
E. Match treatment to need; trauma-informed is not trauma treatment
Maercker et al. (2022) summarize evidence for trauma-focused approaches, including interventions with exposure components, and for flexible multicomponent treatment addressing emotion regulation, relationships, and trauma symptoms. They report trials in which structured skills plus trauma-focused work and extended trauma-focused interventions both improved outcomes. Thus, avoid teaching that remembering traumatic experiences, emotionally activating treatment, or exposure is intrinsically harmful. The central distinction is between collaboratively undertaken, clinically indicated treatment and pressured or poorly attuned exploration.
• For supportive and psychodynamic work. Assess whether the patient’s goals and symptoms can be addressed within the therapist’s competence and treatment frame. Attend to alliance, self-concept, defensive functions, interpersonal patterns, and emotion regulation while tracking impairment and risk.
• When symptoms remain prominent. Discuss evidence-based trauma-focused options, shared priorities, and referral or integration when warranted. Collaboration may involve other medical, psychiatric, or social supports.
• Track change concretely. Look for changes in intrusive symptoms and perceived threat, as well as less global self-condemnation, improved ability to experience and reflect on feelings, increased capacity for closeness, greater agency, and everyday functioning.
A brief in-session decision guide
When the patient becomes silent, compliant, agitated, ashamed, angry, or disconnected, ask yourself: (1) What is happening now, phenomenologically? (2) Is there acute danger, severe dysregulation, or dissociation that needs immediate attention? (3) How might this response be protecting the patient, and what other explanations are possible? (4) What in my manner, intervention, or the treatment frame may be contributing? (5) Would the most helpful next step be to listen, clarify, validate, contain, explore a relational pattern, offer an interpretation, collaborate on an action, or pause? The aim is neither to avoid difficult feelings nor to pursue insight at the expense of the patient’s capacity to participate.
What is well established, and what remains interpretive?
The most solid claims in these three sources concern the validity of the ICD-11 CPTSD symptom pattern; associations of repeated interpersonal trauma with elevated CPTSD risk; common comorbidities and impairment; and improvement with studied trauma-focused and multicomponent treatments (Maercker et al., 2022). The value of respectful enquiry, trust, choice, and avoiding coercive interactions is strongly supported as an ethical and clinically grounded orientation, but the trauma-informed service framework and many individual practices have less direct outcome evidence (Sweeney et al., 2018). Holding, containment, selfobject transferences, and particular dynamic interpretations are useful clinical concepts articulated by Alessi and Kahn (2019), not individually validated causal mechanisms or substitutes for diagnosis and outcome monitoring. The resident’s task is to use these ideas as hypotheses responsive to the patient, rather than as a theory imposed upon them.
References
Alessi, E. J., & Kahn, S. (2019). Using psychodynamic interventions to engage in trauma-informed practice. Journal of Social Work Practice, 33(1), 27–39. https://doi.org/10.1080/02650533.2017.1400959
Maercker, A., Cloitre, M., Bachem, R., Schlumpf, Y. R., Khoury, B., Hitchcock, C., & Bohus, M. (2022). Complex post-traumatic stress disorder. The Lancet, 400(10345), 60–72. https://doi.org/10.1016/S0140-6736(22)00821-2
Sweeney, A., Filson, B., Kennedy, A., Collinson, L., & Gillard, S. (2018). A paradigm shift: Relationships in trauma-informed mental health services. BJPsych Advances, 24(5), 319–333. https://doi.org/10.1192/bja.2018.29