CPTSD

The diagnosis of CPTSD is related to the biologization of mental health

The debate around the diagnosis of CPTSD (Complex Post-Traumatic Stress Disorder) is a product of the “biologization” of mental health. As happens in many fields, psychiatry has been swept up in waves of hopeful beliefs that biology and the tools of medicine (medical diagnostics like blood tests, brain scans, standardized clinical observations, and genetic testing, as well as medical interventions like pharmaceuticals) will ultimately come to treat and cure—or at least manage—what we (with great hopefulness) understand as biologically grounded forms of distress.

We are, in many ways, still riding the wave that began with Prozac with that iconic Newsweek cover, which declared Prozac not just a breakthrough treatment for depression but expressed a promise that all mental suffering could be cured by such treatment. There’s a problem here for Prozac itself. We’ve since learned that Prozac and the class of antidepressants that imitate it aren’t nearly as effective as we believed (wished) they were. But there is a separate, less discussed problem: the hefty task of deciding what sorts of life experiences should be considered mental suffering and therefore, in the category of life experiences that we should consider biological, meaning holding the prospect of being treated in a manner (we hoped) depression could be treated.

CPTSD broadens the understanding of trauma so symptoms can be located as coming from somewhere

CPTSD seems like an important response to the obvious limitations of this biological mode of understanding so much suffering. It also is a response to the very narrow diagnosis of PTSD. Its adherents began by insisting that many forms of suffering, including those that are so often understood as personality disorders and affective disorders (including depression), aren’t biological. These symptoms come from somewhere and are the product of profound, formative, and often chronic, painful, or abusive life experiences. These experiences frequently happened early on in life.

If we set aside the insistence that all such experiences must be understood through the specific designation of trauma, what advocates for CPTSD (and “trauma-informed care”) have done is reinvent non-biological psychology. In a sense, they’ve reinvented psychoanalysis.

CPTSD begs the question: Do we treat individuals better if we cast them as traumatized?

The diagnosis is also kind of a word game related to the stigma of Borderline Personality Disorder, most notably within mental health and healthcare systems (though this stigma is importantly not universal). Part of the challenge of changing the stigmatizing manner in which BPD patients are related to involves inviting clinicians to reflect on how individuals with this presentation make them feel. The defenses of these patients frequently arose complicated, unhelpful, and unkind reactions in even well-intentioned (but inexperienced or poorly trained for what work with those diagnosed with BPD entails) therapists. 

Obviously, this needs to be improved and yet, the application of the diagnosis of CPTSD begs the question: Is that improvement aided or made more difficult by shifting language to a diagnostic label that centralizes victimization (trauma) rather than relational engagement (personality)? Does casting individuals more fully as victims mean we treat them better, both in the sense of approaching them with more humanity and offering better mental health treatments and interventions? Or are we better off teaching therapists to understand the complex experiences of relating to patients with certain histories?

Another concern is how the diagnosis impacts an individual’s understanding of who they are and how they will get better (or if they will)

Understanding the significance of symptoms and locating them as coming from somewhere is a good thing. The concern isn’t how universally we diagnose trauma, but what this means for how that individual understands who they are, their experiences, and how they will get help to get better. And even if they will get better.

The latter depends on what we’re inviting someone to do with that label and what we’re suggesting we and others do with it. On the one hand, saying someone has been traumatized presumes attending to the trauma itself. We look at what happened and help someone heal. On the other hand, in constructing everything as trauma and blurring the distinction between traumatic events and traumatic effects, we increasingly cast a certain inevitability to suffering wherein the diagnosis is meant to function as a kind of permission slip relieving the receiver from many of the significant tasks of both being in the world and getting better. We invite deference as to the special status of the “traumatized” patient as victim and accommodate rather than invite growth. 

In other words, too often in labeling something as trauma, we package it as something that cannot be integrated because it’s too awful. It’s too much. It’s too outside the bounds of experience we believe to be able to be integrated. It is, in a word, unspeakable.

What if, rather than debating what is labeled trauma, we advocated for suffering to be more fully understood as having come from somewhere?

While a diagnosis can (and should) be validating, we need to ask: Does the patient need the construction of trauma specifically to feel validated? Is the same work done in advocating that their suffering needs to be seen and should be investigated as having come from somewhere? Is what they’re asking for (and not asking for but can benefit from) someone who can say both, “I see you” and “I believe your suffering and your struggle. In fact, who you are comes from all of what’s happened to you”? 

Taking an even bigger step back, what if we moved to an understanding of all legitimate objects of psychotherapeutic treatment as formative, the complex end products of formative experiences? This includes trauma to be sure, but also losses, personality, emotional and relational realities of childhood, and social conditions like poverty or broken schools. Maybe rather than calling everything trauma, we need to better understand that everything—depression, anxiety, panic disorder, a host of experiences beyond BPD that we tend to umbrella as personality—as coming from somewhere.

After all, isn’t that what we’re begging for when we ask for a diagnosis of CPTSD? That therapists (and psychiatrists, nurses, and social workers) come to appreciate that who we are and the challenges that some people have in living, relating, and finding peace in the world (and making good use of therapy) are historical, both in the sense of our experiences having a history but also our experiences existing within history.