by Linda Collins, Ph.D. 

History taking with couples often reveals a childhood wherein the chronic relational experiences with one or both parents led to an environment that was emotionally unsafe, unpredictable, and unreliable.   This developmental history might suggest an attachment disorder impacting future adult relationships.  Is this condition also a form of developmental/relational trauma?

Dr. Bessel van der Kolk, identified a condition in 2005 that has been referred to as Developmental Trauma Disorder (DTD). This condition, not formally recognized in the DSM-5, is defined as living in general anxiety or non-stop terror before the age of three.  This kind of trauma occurs prior to the frontal cortex coming on line and cannot be recalled as a discrete event.  Van der Kolk identifies the symptoms of DTD as relational and chronic: the inability to concentrate or regulate feelings, chronic anger, fear, and anxiety, self-loathing, aggression, and self-destructive behavior.

Van der Kolk (2005) identifies insecure attachment and attachment disorder as the cause of developmental trauma. Diagnosing DTD can only be made on the basis of the symptoms, since the defining experience of trauma occurs before it can be recalled. These symptoms are often somatic and not linked to event memories.

Another diagnosis that has been adopted by the traumatic stress field is Complex Trauma Disorder (Aideuis, 2007).  Complex trauma (also not recognized formally in the DSM-5) is used to address “the multi-faceted nature of trauma experienced by children when violence, neglect and fear form the fabric of their early existence” (Aideuis, 2007).  Seven domains of symptoms make-up this diagnosis, including insecure attachment issues, sensory processing issues, emotional regulation issues, alterations in states of consciousness, problems with behavioral control, cognitive difficulties, and problems related to self-concept.

The case example below illustrates the clinical presentation of relational experiences after the age of three that are remembered as emotionally unsafe and frightening.  Both partners in the couple described below have trauma histories that include difficulties with experiencing emotional safety and the reliability of getting their needs met in their caregiving relationships.  One of the partners has a history of other trauma, including early sexual abuse and witnessing  the death of two friends, one by suicide.

Michael and Sherry (names changed for confidentiality) have two children, aged 4 and 6 years.  Their son, 4, just started in a transitional kindergarten program.  He has been diagnosed with ADHD, is very active, and has a hard time following directions and sitting.   Sherry describes, with increasing irritation, that she has been trying to set up a meeting with her son’s school to deal with his special needs, and that they have not responded.

Sherry continues focusing on her concerns in this couples therapy session about her son, listing the ways in which the school staff “doesn’t care about his needs” and their lack of response to her emails.   Sherry’s voice begins to shift from irritation and anger to reflect her fear and hurt.  Tears form in her eyes.  Michael, in an attempt to diffuse the increasing emotion, offers an explanation that the school has a lot on their plate and may simply be delayed in getting back to them. Sherry is triggered by Michael’s suggestion and reads his tone as a judgment about her concerns and reacts defensively.  Michael begins to feel triggered by Sherry’s defensive response, which he perceives as an attack. His efforts to help, he feels, have been rejected and misunderstood.

Both partners appear to be caught in a relationship interaction that felt reminiscent of chronic relational misattunements and emotionally unsafe relationships during their childhoods.  During the intake, Michael revealed that he was sexually abused at 4 years of age by his brother’s friend.  His father was described as quick-tempered, as was his mother.  Michael began to get severe panic attacks at age 23 and has also been diagnosed with Attention Deficit Disorder. He has also struggled with depression most of his life.

Sherry describes growing up with a mother who was preoccupied with her own work life.  Sherry felt perpetually blamed for not doing things the right way.  She began using drugs in her adolescence, but has currently been sober for 16 years.  She has struggled with depression, and in 2015 was diagnosed with rheumatoid arthritis and fibromyalgia.

The ways that the couple described above get “stuck” can be understood more clearly through the lens of the complex relational trauma that both partners experienced.   Susan Johnson (2002) in her book, “Emotionally focused Couple Therapy with Trauma Survivors” points out the importance of beginning to work with couples as described above, by using past events and experiences to “validate the self protective stances partners are taking in the present relationship.”  Janina Fisher (2017) approaches the beginning of treatment by explaining the neurobiology of trauma and helping the couple to see their trauma as the villain rather than one another.  Framing past trauma as their adversary has proven to be very helpful for Sherry and Michael; they could unite around this understanding rather than personalize the trauma-informed reactions.

Sue Johnson (2002) also suggests that therapy with trauma survivors may include the following stages of intervention. Stage 1 comprises stabilization where safety is established, and the couple understands how the effects of trauma and lack of security shape their responses to one another.  Stage 2 is focused on restructuring the bond between partners, and Stage 3 is focused on a process of integration.

The case example above demonstrates how trauma history of one or both partners shapes and contributes to their relational problems. The emerging diagnoses of Developmental Trauma Disorder and Complex Trauma Disorder offer the clinician a way of understanding early trauma that does not fit into the more event-oriented trauma of the Post-traumatic Stress Disorder (PTSD) diagnosis.

Intervention models such as Johnson (2002) and Fisher (2017) reflect the need to alter the couple treatment approach based on an understanding of the trauma histories of one or both partners.  Validating the defensive responses of both partners shaped by their trauma histories models compassion and understanding for both partners.  Integrating a psycho-educational approach to understanding trauma and the dysregulation of the nervous system in response to trauma can help each partner to depersonalize some of the automatic and reactive responses received from their partners.

References

Aideuis, D, (2007), Promoting Attachment and Emotional Regulation of Children with Complex Trauma Disorder, International Journal of Behavioral Consultation and Therapy, Vol.3, No.4, pp.546-554.

Fisher, J. (2017), Healing the Fragmented Selves of Trauma Survivors, Routledge.

Johnson, S. (2002), Emotionally Focused Couples Therapy with Trauma Survivors, Guilford Family Therapy Series.

Van der Kolk (2014), The Body Keeps the Score-Brain, Mind and Body in the Healing of Trauma, Penguin Group.

Van der Kolk (2005), Complex Developmental Trauma-Editorial Comments, Journal of Traumatic Stress, Vol.18, Issue 5, pp.385-388.

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Dr. Collins has completed advanced training with the Gottman method of couples therapy.  She is certified as a Somatic Experiencing Practitioner and specializes in working with individuals and couples with a trauma history.