PTSD and complex PTSD treatment, online across New Zealand

What is PTSD?

Post-traumatic stress disorder (PTSD) is a condition that can develop after exposure to an extremely threatening or horrific event. It involves re-experiencing the event in the present through flashbacks or nightmares, avoiding reminders, and a persistent sense of current threat. Complex PTSD adds difficulties with emotions, self-worth and relationships. Both respond to trauma-focused psychological therapy.

The four symptom clusters of PTSD

Most people who live through something terrible have a strong reaction for days or weeks afterwards. PTSD is when that reaction doesn't settle, or returns later, and keeps running in four recognisable ways.

• Re-experiencing. Intrusive memories that arrive uninvited while you're making dinner. Nightmares that replay the event or its themes. Flashbacks, where for a few seconds or minutes you feel as if you're back there: the sounds, the smells, the fear in your body.
• Avoidance. Steering clear of places, people, conversations, programmes or even thoughts that bring it back. Declining the tangi because the last one was the funeral. Never driving through that town again. Keeping so busy that there is no room for the memory to surface.
• Hyperarousal. A body on permanent watch. Startling at a car door slamming. Sitting where you can see the entrance. Checking the locks twice. Difficulty concentrating, broken sleep, and a short fuse that surprises you and the people around you.
• Negative changes in mood and beliefs. Feeling numb or cut off. Losing interest in things you used to love. A persistent sense that you are to blame, that you are weak, that people can't be trusted, that the world is dangerous. Shame is common, and so is a sense of being changed for good.

NICE, the UK's clinical guideline body, describes exactly these clusters and notes that PTSD often comes with emotional numbing, dissociation, difficulty regulating emotions, problems in relationships and a negative view of yourself. Some people don't recognise their experience as PTSD for years.

Complex PTSD: when trauma was repeated or prolonged

The World Health Organization's ICD-11 added complex PTSD as a separate diagnosis. It typically follows events that were prolonged or repeated and from which escape was difficult or impossible: childhood abuse or neglect, family violence, captivity, prolonged bullying, or growing up in a household where fear was the weather.

Complex PTSD includes all the core PTSD symptoms, plus three further groups of difficulties that researchers call disturbances in self-organisation:

• Emotion regulation. Feelings that are too big and too fast, or a shutdown where nothing is felt at all. Difficulty calming down once upset.
• Negative self-concept. A deep, steady belief that you are worthless, defective or to blame, often with intense shame or guilt.
• Relationships. Trouble feeling close to people or sustaining relationships, swinging between wanting connection and bracing for it to go wrong.

If this sounds like you, it doesn't mean you are broken or untreatable. It means therapy is likely to spend longer on the early phase, building skills and trust before working with memories, and that the work may touch on relationships and self-worth as well as specific events. Our relationships and attachment page and emotional dysregulation page cover related ground.

Questions a psychologist would explore

This page isn't a diagnostic test, and a list of symptoms online can't tell you whether you have PTSD. It can help, though, to know the kinds of questions a psychologist will work through with you in an assessment:

• What happened, in as much or as little detail as you want to share, and how long ago?
• How often do memories, images or dreams of it come back without you choosing them?
• What do you avoid now that you didn't before, and what has that cost you?
• How is your sleep, your concentration, your startle response, your temper?
• What do you believe about yourself, other people and the world since it happened?
• How are things at work, at home and in your relationships?
• Are you using alcohol or other substances to cope? Are you ever having thoughts of not wanting to be here?

Your psychologist may also use a short standardised questionnaire, repeated over the course of therapy, so you can both see whether things are shifting. Assessment usually takes one or two sessions and is itself a chance to be heard without judgement.

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What the guidelines recommend

Three major sources agree on first-line treatment for adults with PTSD.

NICE guideline NG116 recommends offering individual trauma-focused CBT to adults with PTSD or clinically important symptoms who present more than a month after the trauma, naming cognitive processing therapy, cognitive therapy for PTSD, narrative exposure therapy and prolonged exposure as examples. It recommends offering EMDR to adults who present more than three months after a non-combat trauma, and considering it between one and three months if the person prefers it.

The ISTSS 2018 guidelines, developed by the International Society for Traumatic Stress Studies, give their strongest recommendation to five treatments for adults: cognitive processing therapy, cognitive therapy, EMDR, individual trauma-focused CBT and prolonged exposure. The World Health Organization likewise recommends CBT with a trauma focus or EMDR.

A 2020 network meta-analysis of 90 trials found EMDR and trauma-focused CBT were the interventions most consistently more effective than waiting lists, though the authors cautioned that many trials carried a high risk of bias.

On medication: guidelines treat psychological therapy as the first choice, with medication an option for some people, for example where therapy isn't wanted or available, or where depression is prominent. Psychologists don't prescribe. If you want to explore medication, or are already on it, talk to your GP or a psychiatrist; therapy and medication can run alongside each other.

What a course of treatment looks like

Therapy for PTSD has a shape, even though the details are tailored to you.

Assessment and planning (one to two sessions). Understanding what happened, what is happening now and what you want back. Agreeing which approach to use and roughly how long to expect.

Stabilisation (a few sessions, longer for complex PTSD). Learning to ground yourself when a flashback hits, to settle your body, to sleep a little better, and to notice early warning signs. Understanding why avoidance keeps PTSD going. Nothing here requires you to go into the memory.

Processing (the middle of therapy). With trauma-focused CBT, this means working through the memory in a structured way, updating the "hotspots" where meanings like "I'm going to die" or "it was my fault" got stuck, and gradually reclaiming avoided places and activities. With EMDR, it means targeting memories with sets of eye movements until they lose their intensity and new, more accurate beliefs settle in.

Consolidation. Planning for triggers you can predict (an anniversary, a court date, a return to the place), building the life PTSD interrupted, and agreeing how to end or space out sessions.

Guidelines describe a typical course as somewhere between roughly 8 and 12 sessions, with more where someone has lived through multiple traumas. At Mindwell sessions are 50 minutes, usually weekly, and you can pause or stop at any time.

Treating PTSD online

Trauma-focused therapy translates well to video. A meta-analysis covering more than 100 studies found no meaningful difference in outcome between video and in-person psychotherapy, with PTSD among the conditions studied. An intensive programme combining EMDR and prolonged exposure, delivered entirely remotely to people with PTSD and complex PTSD, reported large and lasting symptom reductions with no drop-outs.

For many people with PTSD, online has specific advantages. The clinic waiting room, the drive, the unfamiliar building and the walk back to the car afterwards are all things a hypervigilant nervous system has to manage. At home you choose the chair, the lighting and the door you can see. If a session is hard, you are already somewhere safe when it ends.

Your psychologist will usually agree with you early on what happens if you dissociate or become very distressed on a call: how they will bring you back, who they can contact, and what you will do afterwards. This is a precaution, not a sign anything is expected to go wrong.

When PTSD comes with other difficulties

PTSD rarely travels alone. Depression is common, as is heavy drinking or drug use that started as a way to sleep or switch off. Anger and irritability are more pronounced in PTSD than in other anxiety-related conditions, and often the first thing a partner notices. Some people experience dissociation, feeling unreal, detached or "not there", which changes how therapy is paced.

None of these rule out treatment. Your psychologist will help you work out what to address first and how the pieces fit. Sometimes treating the PTSD lifts the depression with it; sometimes mood or substance use needs attention before memory work is safe. Our pages on depression and anger and irritability go into those overlaps.

PTSD treatment at Mindwell

Mindwell is a telehealth practice: you see a New Zealand-registered psychologist by video from wherever you are, without a GP referral. Booking is online and first sessions are usually available within 7 days. Sessions cost $199 + GST ($228.85 incl. GST) and are paid at booking; we provide receipts for health-insurance claims.

We are not an ACC provider. If your PTSD follows sexual abuse or assault, ACC funds therapy with ACC-registered providers at no cost through its Sensitive Claims Service; see our trauma therapy page for how to access that. Mindwell is also not a crisis service. If you are in immediate danger call 111; for free 24/7 support call or text 1737.

Related support: Trauma therapy · EMDR therapy · Emotional dysregulation · Anxiety therapy