Individuals may come from families where traumatic events are embedded in their experiences: chronic illness and death, physical and sexual abuse, domestic violence, homicide and suicide, incarceration, alcohol and drug abuse and associated behaviors, housing crises, and other disruptive experiences. Children may experience chronic stress that may not qualify for a PTSD diagnosis but function in ways that are clearly consequential to such early experiences. Children and the adults they become may show every DSM-IV criterion from B to F without having experienced an identifiable specific traumatic event- criterion A. Hyper-arousal and the other uncontrollable emotional and behavioral reactivity clearly disrupt the individual and his or her relationships. However, the therapist would not be professionally isolated to consider PTSD or PTSD-like symptoms in individuals without a specific traumatic event but who endured chronic stressful experiences (unrelenting pressure, child neglect, emotional humiliation, insecure attachment, being bullied, hiding sexuality, rigid intolerant religious upbringing, political oppression, observing parental domestic violence, and so forth). An adjustment disorder may be appropriate alternative diagnosis if the stressor is considered not extreme enough by the criteria (American Academy of Child and Adolescent Psychiatry, 2010). Other differential diagnosis options may be considered. The professional discourse has led to a case made for the inclusion of a new diagnosis- developmental trauma disorder in the next revision of the Diagnostic and Statistical Manual- Fifth Edition. "…the PTSD diagnosis does not capture the developmental impact of childhood trauma: the complex disruptions of affect regulation, the disturbed attachment patterns, the rapid behavioral regressions and shifts in emotional states, the loss of autonomous strivings, the aggressive behavior against self and others, the failure to achieve developmental competencies; the loss of bodily regulation in the areas of sleep, food and self-care; the altered schemas of the world; the anticipatory behavior and traumatic expectations; the multiple somatic problems, from gastrointestinal distress to headaches; the apparent lack of awareness of danger and resulting self endangering behaviors; the self-hatred and self blame and the chronic feelings of ineffectiveness" (van der Belk, 2010, page 9)
The therapist may find that traumatic childhood experiences have significantly affected an individual up to and including joining in a couple. Individuals with alcoholic parents or from homes of domestic violence for example would be unlikely to have secure childhood experiences. "…symptomatology tends to be pervasive and multifaceted, and is likely to include depression, various medical illnesses, as well as a variety of impulsive and self destructive behaviors… The traumatic stress field has adopted the term 'Complex Trauma' to describe the experience of multiple and/or chronic and prolonged, developmentally adverse traumatic events, most often of an interpersonal nature (e.g., sexual or physical abuse, war, community violence) and early-life onset." In the Adverse Childhood Experiences (ACE) study by Kaiser Permanente and the Center for Disease Control, 17,337 adult HMO members reported significant rates of negative experiences: 11.0% emotional abuse, 30.1% physical abuse, 19.9% sexual abuse; 23.5% exposure to family alcohol abuse, 18.8% to mental illness, 12.5% witnessed mothers being battered, and 4.9% reported family drug abuse. The study indicates a strong relationship to adult health issues and confirms a relationship between "adverse childhood experiences and depression, suicide attempts, alcoholism, drug abuse, sexual promiscuity, domestic violence, cigarette smoking, obesity, physical inactivity, and sexually transmitted diseases." In addition to emotional, behavioral, and social consequences, individuals also experience increased physical and medical problems (van der Belk, 2010, page 2). The therapist may focus on looking for distinct traumatic events in his or her assessment. Such events can create discrete conditioned behaviors and biologically driven recurrent and intrusive re-experiencing of the trauma as expressed in the PTSD diagnosis. On the other hand, there might not be a specific trauma.
The therapist needs to know that chronic as opposed to acute stressors (mistreatment or trauma) can have "...pervasive effects on the development of mind and brain. Chronic trauma interferes with neurobiological development… and the capacity to integrate sensory, emotional and cognitive information into a cohesive whole. Developmental trauma sets the stage for unfocused responses to subsequent stress… People with childhood histories of trauma, abuse and neglect make up almost our entire criminal justice population: physical abuse and neglect are associated with a very high rates of arrest for violent offenses. In one prospective study of victims of abuse and neglect, almost half were arrested for non-traffic related offenses by age 32. Seventy-five percent of perpetrators of child sexual abuse report to have themselves been sexually abused during childhood. These data suggest that most interpersonal trauma on children is perpetuated by victims who grow up to become perpetrators and/or repeat victims of violence. This tendency to repeat represents an integral aspect of the cycle of violence in our society"(van der Belk, 2010, page 3-4).
When parents are able to respond to their children when they feel distress, children are more likely to develop secure attachment. Parents are able to soothe fears and desperate feelings triggered by distress or trauma. If the parents are supportive but are flustered or disorganized, then children tend to follow their model and be similarly disorganized. Worse is when the distress becomes overwhelming or if the parents are the cause of the distress. As a result, children cannot manage their emotional reactivity. "This causes a breakdown in their capacity to process, integrate and categorize what is happening: at the core of traumatic stress is a breakdown in the capacity to regulate internal states." When the distress is chronic, they may disassociate. Sensations, feelings, and thoughts disassociate into sensory fragments. This makes experience difficult to understand and stymies planning for self-care and problem solving. When parents are "emotionally absent, inconsistent, frustrating, violent, intrusive, or neglectful, children are liable to become intolerably distressed and unlikely to develop a sense that the external environment is able to provide relief." With resulting insecure attachment, children do not trust that others will help them and become unable to self-manage their emotional reactions. Resulting intense anger, anxiety, and neediness to be cared for can cause disassociation, acting out behavior, or aggression. Overly aroused, they may learn to ignore feelings or thoughts that would be too disturbing. Feeling out of control and lacking stability, children become helpless. Since they cannot understand what is happening or have any control about making changes, when triggered by something scary they go into classic fight, flight, or freeze reactions. They experience everything in a truncated manner without learning from it. "Subsequently, when exposed to reminders of a trauma (sensations, physiological states, images, sounds, situations) they tend to behave as if they were traumatized all over again – as a catastrophe. Many problems of traumatized children can be understood as efforts to minimize objective threat and to regulate their emotional distress."
Unless caregivers understand the nature of such re-enactments they are liable to label the child as "oppositional", 'rebellious", "unmotivated", and "antisocial" (van der Belk, 2010, page 4-5). When caregivers such as parents and teachers are negligent or unaware of the chronic trauma of children, the children are on their own trying to self-regulate emotionally. Self-image or self-definition issues arise: lack of a continuous sense of self, poorly modulation of affect and impulse control (such as aggression against self and others), insecurity about others reliability and predictability (distrust, suspiciousness, and intimacy problems), and resultant social isolation. In addition, they suffer "from distinct alterations in states of consciousness, with amnesia, hypermnesia, dissociation, depersonalization and derealization, flashbacks and nightmares of specific events, school problems, difficulties in attention regulation, with orientation in time and space and they suffer from sensorimotor developmental disorders. They often are literally are 'out of touch' with their feelings, and often have no language to describe internal states" (page 6-7). Aggression, impulse problems, inattention, and disassociation negatively affect relationships with family, adult caregivers, and peers in childhood, and subsequently, complicate vocational, social, and especially intimate relationships in adulthood. The therapist needs to be vigilant for issues extending into adulthood that manifest in negative consequences including substance abuse, eating disorders, personality disorders, and physical problems. "The results of the DSM IV Field Trial suggested that trauma has its most pervasive impact during the first decade of life and becomes more circumscribed, i.e., more like 'pure' PTSD, with age" (page 8).
Childhood and family experiences with trauma can exhibit in unpredictable and erratic ways in people's relationships. Feld (2004, page 421) cited research that traumatized people try to regulate stress with avoidant, disorganized, or ambivalent strategies. From disorganized and patterns of interaction lacking coherence, they often get caught up in battles and/or become disengaged, blaming, and distrustful. Since such an individual did not feel safe and secure in his or her family-of-origin, there is no experiential reference to assume safety or security in current relationships. Since trauma is often associated with intimacy and love interactions, the individual may continue to associate trauma and love or intimacy. Are Molly's blaming and distrustful reactions to Cole, the person she loves a result of early trauma? Does Cole disconnect from Molly and blame her to manage his own stress reactions when love for and anger at Molly simultaneous overload him emotionally? How does intrusive recollection of prior betrayals by intimate caregivers create paranoid sensitivity to each other's actions? PTSD symptoms may not only arise frequently in a couple's relationship, but the couple's relationship may be among the most powerful and opportune venue to address PTSD. It may only be in the intensity of and investment in the couple's relationship, that partners will confront their deep trauma. "Posttraumatic stress disorder (PTSD) has been associated with a myriad of intimate relationship problems, leading a number of researchers and clinicians to encourage inclusion of traumatized individuals' partners in treatment" (Monson et al., 2004, page 341). In the intimate relationship, an individual often exhibits his or her greatest vulnerability and reveals his or her greatest needs. Unfortunately, PTSD may fundamentally disable an individual for seeking the validation necessary to recover from family or developmentally caused PTSD deficits. "As a result, an individual most in need of holding would be unable to ask for or elicit it... an aim of couple therapy is to help the partners to become aware of and better regulate the cocreated, interactive aspects of their relationship, which includes the aspect of listening to each other" (page 421).
When a person's relationship or intimacy is threatened, he or she activates behaviors instinctively from his or her attachment style. The attachment style developed in childhood tries to recover and maintain attachment against potential loss. Bowlby (1980) felt early reciprocal interactions between mother and child creates the model for dealing with future intimacy. Individuals therefore make connections and attachments from the models experience in the family-of-origin. "These working models can be observed in patterns that partners establish with each other. They interact in a reciprocal influencing system. The patterns embedded in the system can cause problems for the couple. Although these behaviors may seem disruptive in the present relationship, the partner unconsciously feels they are needed to maintain the attachment" (Feld, 2004, page 422). If unproductive behaviors such as angry retorts, overly vigilant scrutiny, and isolating are part of the instinctive model, they create a negative interactional cycle that confirms negative expectations and perceptions. The problematic habitual attachment behavior continues to exacerbate the negativity in an ever more destructive relationship cycle. The therapist should try to break this cycle by developing understanding, accessibility, and responsiveness in both partners. This requires each individual to understand and accept him or herself. When trauma is hidden or only implicitly acknowledged or understood, therapy is challenged to uncover traumatic triggers that act as emotional and psychic landmines. Cole and Molly need to distinguish each other's actions from intrusive feelings and memories from within stressful and/or traumatic prior experiences. The distinction between stressful experiences that may cause neurotic sensitivity and projection and traumatic events causing PTSD symptoms may be less important in therapy than identifying and exploring their impact on perception and functioning. Asserting a label is less important than the therapist facilitating a safe environment for exploring and revealing individual and couple's relationship dynamics. Finding previously hidden or unacknowledged traumatic experiences can be triggering and threatening to both the traumatized individual and to his or her partner. The therapist must manage the process so that revelation is validating rather than devastating or re-traumatizing. Understanding the humanity of their processes and behaviors validates Cole and Molly. When the therapist affirms their need to survive their challenges, it counters their lifelong shame from their dysfunctional processes and behaviors.