Complex PTSD – the missing piece for many Third Culture Kids

by | Aug 14, 2017 | Blog | 2 comments

As a follow up to my previous interview with PTSD practioners (read more here) I was prompted to seek out a therapist who could shed some light on Complex PTSD (or C-PTSD). And Mary-Clare de Echevarria very kindly stepped into the breach. In this post, she outlines the diagnostic and experiential differences between PTSD and C-PTSD and her clients’ treatment experiences.

Though I do not work directly with PTSD, I have gained a growing appreciation for the number of Third Culture Kids who have experiences of trauma featuring strongly throughout their life stories. And I am deeply grateful for therapists such as Mary-Clare who can so expertly support those battling both PTSD and C-PTSD.

Mary-Clare de Echevarria is a UKCP-registered psychotherapist, supervisor and training supervisor with over 20 years’ experience. She is a staff member at The Centre for Counselling and Psychotherapy Education, London, and teaches her own series of workshops on complex trauma, The Missing Piece™. Her website can be found at Primary Light.

What’s the difference between PTSD and Complex PTSD, or C-PTSD?


Trauma is an overwhelming negative experience that’s bigger than our capacity to integrate it. A single experience of ‘loud T trauma’, such as physical, emotional or sexual abuse, witnessing violence, 9/11 or a natural disaster, can lead to PTSD.

C-PTSD comes from ongoing trauma in childhood or adolescence: experiences of quiet t trauma, often coupled with loud T trauma. ‘Quiet t trauma’ refers to less obvious trauma such as not being understood or listened to; not being allowed to have feelings or needs, or not expressing them because your parents/caregivers can’t deal with them; not feeling safe or secure; not having anyone to go to for comfort or protection and feeling utterly alone; or constantly having to break attachments, eg through frequent moves or being sent to boarding school. C-PTSD is also known as complex or developmental trauma.

What draws you to working with clients with C-PTSD?

It’s the realisation that complex trauma underpins everything, and yet this is often not recognised. For so many people, an understanding of C-PTSD and dissociation is the missing piece that allows them to make sense of what they feel and the ways in which their past has shaped them. When you know how to recognise and work with it, the changes that come about can seem magical as they are so real and tangible. My students and clients who have C-PTSD are among the strongest, most creative and inspiring people I’ve met. It’s a privilege to work with them and help them to reconnect with parts of themselves that they had to ‘put away’, or dissociate, in order to survive. They learn to be kinder and gentler towards themselves, and are no longer overshadowed by constant background pain, anxiety or self-doubt. They start to feel powerful, competent and grounded in the present, in touch with themselves and able to stand up for themselves quite naturally and spontaneously. They say things like ‘I feel that I’m really living for the first time’.

What are the common presenting symptoms of C-PTSD that you identify in your clients?

As a therapist you have to learn to look for ‘intrusions into day-to-day functioning’: thoughts, feelings and behaviours that come from the past. They’re very real in the present and affect people’s ability to function in their lives, but they’re memories: emotional and physical memories of what you once felt. They can include critical voices in your head; persistent feelings of helplessness, emptiness, aloneness, or not being good enough; hypervigilance – waiting for something bad to happen; feeling that you have to be the strong one all the time, or that good things are for other people; intense reactions that seem out of proportion to the present situation; anxiety, depression or strange moods that seem to come from nowhere, then they vanish just as suddenly and you may feel ‘what was all that about?’. You may find it hard to have intimate relationships, to trust others or let them come close; you may be drawn to unavailable people, or find that you can’t always parent your children as you would want to.

Are there ‘mental blocks’ that interfere or complicate treatment and recovery from C-PTSD, that are shared by your clients?

Sometimes people are (understandably) afraid that they’ll have to ‘go back into the past’ and feel terrible. That isn’t the case: the aim of trauma therapy now is to help people to process traumatic experiences without becoming overwhelmed. It isn’t about going back into the past, but working with and resolving memories of the past that are coming into the person’s present. It’s essential that clients learn to feel painful feelings just for a moment, long enough to acknowledge them, then immediately bring themselves back to a place of feeling strong, safe, grounded and connected in the present.

What factors seem to be the most helpful in your clients’ recovery?

Psychoeducation – helping clients to understand what happened to them and how to recover, then therapy isn’t a mysterious process that they have to go along with: they know what’s going on and what to do to make themselves feel better. Having a therapist who is a real, attuned person. Above all, having a therapist who knows how to recognise and work with complex trauma and dissociation, is not at all afraid of it and understands that it’s a set of totally natural survival strategies.

Are there specific processes or treatments that you’d recommend in the treatment of C-PTSD, that your clients find especially effective?

A therapy that recognises dissociated states, sometimes known as ‘ego state therapy’. EMDR and interventions from sensorimotor psychotherapy or Somatic Experiencing, woven into an integrative, relational ego-state therapy. It’s essential to work with the body in trauma therapy, and I can’t recommend yoga highly enough as a way of connecting with yourself and your body and learning to feel strong, powerful, centred and relaxed in the present moment. Many of the interventions that I use regularly in my practice are drawn from yoga therapy.

Thank you so much Mary-Clare, for your work and for your insight.

If you have any questions for Mary-Clare, do contact her on the link above.



  1. Dan Elyea

    Thank you for your follow-up efforts, Dr. Rachel. Very interesting about the distributed or cumulative stress factors. Even to a lay person.


    • Dr. Rachel Cason

      Thank you for reading, Dan!


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