Why is recovery from CPTSD non-linear?

Periods of stability often alternate with periods where old symptoms resurface or new ones emerge, and clients sometimes need more support rather than less at particular points. This is consistent with Herman’s (1992) three-phase model of trauma recovery, where each phase may need to be revisited. Non-linearity is not a sign that treatment is failing; it is part of how processing of long-held material typically unfolds.

What is the window of tolerance?

Siegel’s (1999) concept describes the range of arousal within which a person can think, feel, and act effectively. Trauma narrows this window. Dysregulation pushes a person above it (hyperarousal) or below it (hypoarousal). One reliable marker of progress in CPTSD treatment is faster return to the window after a trigger.

What Progress in Complex PTSD Treatment Actually Looks Like

Q: What does progress in Complex PTSD treatment look like?

Progress in CPTSD is typically defined by increased nervous system flexibility rather than absence of symptoms. Reliable markers include earlier awareness of dysregulation before full activation, faster return to the window of tolerance after a trigger, greater agency in the moment, and behavioural change that runs ahead of felt change.

Q: How is CPTSD different from PTSD?

Complex PTSD was formalised in the ICD-11 as a distinct diagnosis. It requires the core PTSD criteria of re-experiencing, avoidance, and a sense of current threat, plus three additional clusters known as disturbances in self-organisation. These are affective dysregulation, negative self-concept, and difficulties in relationships. CPTSD is typically associated with prolonged or repeated trauma, particularly during developmentally sensitive periods.

May 15
6 min read

How recovery in Complex PTSD typically unfolds, what to watch for, and why progress often does not feel like progress

Progress in Complex PTSD (CPTSD) treatment is typically defined by increased nervous system flexibility rather than absence of symptoms. Reliable markers include earlier awareness of dysregulation before full activation, faster return to the window of tolerance after a trigger (Siegel, 1999), greater agency in the moment, and behavioural change that runs ahead of felt change. Recovery is typically non-linear, consistent with Herman’s (1992) three-phase model of safety, remembrance and mourning, and reconnection. CPTSD was formalised in the ICD-11 (Cloitre et al., 2018; Brewin et al., 2017) and is diagnosed by the core PTSD criteria plus three additional clusters of disturbances in self-organisation. Evidence-based treatments include trauma-focused cognitive-behavioural therapy, EMDR, and the STAIR program (Cloitre, Cohen, & Koenen, 2006).

Blurred image of a person with eyes closed, double exposure effect, in warm orange light. Dissociative and dreamy atmosphere.

Most people coming into therapy for Complex Post-Traumatic Stress Disorder (CPTSD) have an idea in mind about what progress should look like. The idea is usually some version of feeling calm, sleeping well, no longer being triggered, and functioning as though the trauma never happened. The expectation is reasonable. It is also rarely what recovery actually looks like, particularly in the earlier stages of work.

Clinically, progress in CPTSD treatment is more subtle than that and shows up in places that are easy to miss. Naming what to watch for is part of the work, because clients who do not know what progress looks like often miss it when it is happening, and conclude that nothing is changing when in fact a lot is.

What CPTSD is, briefly

Complex PTSD was formalised as a diagnosis in the ICD-11 (Cloitre et al., 2018; Brewin et al., 2017). It requires the core PTSD criteria of re-experiencing, avoidance, and a sense of current threat, alongside three additional clusters known as disturbances in self-organisation. These are affective dysregulation, negative self-concept, and difficulties in relationships. The diagnosis is typically associated with prolonged or repeated trauma from which escape was difficult or impossible, particularly during developmentally sensitive periods.

CPTSD shares ground with other diagnoses, including borderline personality disorder, dissociative disorders, and major depression, and good differential assessment is part of the clinical work. The International Trauma Questionnaire (Cloitre et al., 2018) is one of the validated tools used to distinguish PTSD from CPTSD and to identify the disturbances in self-organisation that mark the latter.

How progress in complex PTSD treatment actually shows up

Several patterns recur in clinical work, and each is a meaningful indicator of recovery even when the client does not feel "better" in the way they expected to.

Earlier awareness of dysregulation

Early in treatment, clients often describe getting overwhelmed without warning. Something happens, and they are already activated before they have any awareness of what has shifted. As recovery progresses, the awareness moves forward. Clients begin to notice the early signs of dysregulation, the body cues, the thought patterns, the change in attention, before they are fully inside it. This earlier awareness is one of the most consistent markers of progress and is often the first thing to shift.

Faster return to the window of tolerance

Siegel’s (1999) concept of the window of tolerance describes the range of arousal within which a person can think, feel, and act effectively. Trauma narrows this window, and dysregulation pushes a person above it (hyperarousal) or below it (hypoarousal). One reliable marker of progress is that the time taken to return to the window after a trigger gets shorter. The trigger may still happen. The intensity may still be considerable. But the recovery is faster, and that compression of the recovery curve is meaningful clinical change.

Increased agency in the moment

Trauma responses are by nature automatic. They are designed by the nervous system to bypass deliberation in the service of immediate survival, which made sense at the time the patterns were laid down. As recovery proceeds, the automatic response loses some of its absolute quality. The client starts to notice the response and, in some moments, to choose something different. This shift from automatic reaction to chosen response is a substantial clinical marker, even when the chosen response is small or imperfect.

Behavioural change before felt change

A common pattern in CPTSD recovery is that behaviour changes before feelings change. A client may set a limit with a family member while their heart is racing. They may rest when guilt is telling them to keep going. They may seek connection when shame is telling them to hide. The internal experience does not match the action yet, and the action is still progress. The feelings tend to follow the behaviour, often with a lag of weeks or months. Clients who wait for the feeling before changing the behaviour often wait a long time.

Reduction in intensity rather than elimination

Triggers do not generally disappear in CPTSD recovery. They become less intense, less frequent, and less dominant. Old material may still surface, particularly under stress, sleep deprivation, or significant life events. The work is not to eliminate the trauma response (which the nervous system will not fully agree to) but to reduce its grip and increase the resources available alongside it.

Why progress is non-linear

Recovery from CPTSD is rarely tidy. Periods of stability often alternate with periods where old symptoms resurface or new ones emerge, and clients sometimes need more support rather than less at particular points. This is consistent with what Herman (1992) described in her foundational three-phase model of trauma recovery, where each phase (safety, remembrance and mourning, and reconnection) involves its own difficulties and may need to be revisited.

The non-linearity is not a sign that treatment is failing. It is a sign that the system is processing material that has been carried for a long time. Clinically, the work is to maintain a steady frame, hold the longer arc in mind, and support the client through the parts of the work that feel like setbacks but are often where the substantial processing is happening.

Nervous system regulation as the foundation

Across most contemporary CPTSD frameworks, work with the nervous system sits at the base of what treatment is doing. This is not the only level of work, and trauma processing, narrative repair, relational repair, and meaning-making all sit alongside it. But without a degree of nervous system regulation, the other work tends to be slower and more difficult. Treatment approaches with a strong evidence base include trauma-focused cognitive-behavioural therapy, eye movement desensitisation and reprocessing (EMDR), and skills-based programs like STAIR (Skills Training in Affective and Interpersonal Regulation; Cloitre, Cohen, & Koenen, 2006), with the latter often used as a stabilisation phase before deeper trauma processing.

What I would suggest clients keep in mind

Progress in complex PTSD treatment looks like increased flexibility rather than absence of symptoms. It looks like earlier noticing, faster recovery, more chosen response, and behavioural change that runs ahead of how things feel. It does not look impressive from outside, particularly in the earlier stages. If your healing does not look like the version you imagined, this is not evidence that it is not happening.

Getting in touch

Behavioural Edge Psychology offers trauma-informed therapy for adults, including treatment for PTSD and Complex PTSD. Consulting rooms are in Caulfield South and St Kilda, with telehealth available across Victoria. You can book at behavioural-edge-psychology.au4.cliniko.com/bookings or contact the practice on 03 8771 4315.

References

Brewin, C. R., Cloitre, M., Hyland, P., Shevlin, M., Maercker, A., Bryant, R. A., Humayun, A., Jones, L. M., Kagee, A., Rousseau, C., Somasundaram, D., Suzuki, Y., Wessely, S., van Ommeren, M., & Reed, G. M. (2017). A review of current evidence regarding the ICD-11 proposals for diagnosing PTSD and complex PTSD. Clinical Psychology Review, 58, 1 to 15.
Cloitre, M., Cohen, L. R., & Koenen, K. C. (2006). Treating survivors of childhood abuse, psychotherapy for the interrupted life. New York, Guilford Press.
Cloitre, M., Shevlin, M., Brewin, C. R., Bisson, J. I., Roberts, N. P., Maercker, A., Karatzias, T., & Hyland, P. (2018). The International Trauma Questionnaire, development of a self-report measure of ICD-11 PTSD and complex PTSD. Acta Psychiatrica Scandinavica, 138(6), 536 to 546.
Herman, J. L. (1992). Trauma and recovery. New York, Basic Books.
Siegel, D. J. (1999). The developing mind, toward a neurobiology of interpersonal experience. New York, Guilford Press.

About the author

Dr Sarah Fischer is the Principal Psychologist and CEO of Behavioural Edge Psychology, with consulting rooms in Caulfield South and St Kilda. She holds a PhD in Psychology from Deakin University and is registered with AHPRA, endorsed in organisational psychology. She also serves as the Bar psychologist to the Victorian Bar and holds a casual academic appointment at Deakin University.

Her clinical work sits at the intersection of evidence-based practice, trauma-informed care, and neurodiversity-affirming assessment. Her published research spans psychological safety, organisational trauma, trust and leadership, and has appeared in the Australian Journal of Psychology, Frontiers in Psychology, the Journal of Healthcare Leadership.

To book an appointment, visit behavioural-edge-psychology.au4.cliniko.com/bookings or contact the practice on 03 8771 4315.

If you are in crisis, please contact Lifeline on 13 11 14 or 000 in an emergency.