TRMA 810 Complex Trauma Sample Paper
Complex trauma is defined by the receptiveness in the causes and prolonged nature of the events. These traumatic events are different from the one-off events such as automobile accidents and natural disasters. Complex trauma is mainly caused by child maltreatment, bullying, and domestic violence. These causes are more likely to be repetitive because they occur in a closed interpersonal sphere. Child maltreatment in complex trauma includes child physical abuse, sexual abuse, and child neglect. These events occur when the child develops thinking, behavior, and emotions.
When they fail, they try to make social attachments that result in abnormalities in affect, behavior, self-concept, cognition, and interpersonal relationships. Complexly traumatized children present mostly in the youthful and adult years with dissociation, altered behavior, poor interpersonal relationships, guilt self-blame, and reduced intellectual disability compared with their mates of similar age brackets. Children’s normal growth involves forming strong emotional attachments and cognitive capabilities by learning from the caregiver (Farina et al., 2019).
When the caregiver is unable to provide this support or provides it in the wrong way, the child gets confusion in registration of the learning and thus rigidity in behavior. Long-term effects include personality disorder and substance use (Dye, 2018). Antisocial and paranoid personality disorders have been reported. There is no defined treatment for complex trauma. However, trials of interventions used in post-traumatic stress disorder (PTSD) have been used. The National Child Traumatic Stress Network (NCTSN) recommended a psychotherapy plan that addresses the symptoms of complex trauma.
Keywords: complex trauma, child abuse, child neglect, child sexual abuse, personality disorder
Complex trauma presents as a double aspect issue in traumatology because it is marked by multiple exposures to repeated traumatic events and outcomes in the short term and long term. Compared to one-off incident trauma, also called single incident trauma, complex trauma has more complex outcomes in the short term and adult life. Complex trauma is usually seen in children but can occur in adults. Various trauma terms are overlapping and have been used interchangeably with complex trauma. The terms developmental trauma, early retention trauma, and attachment trauma have been used overlappingly with complex trauma (Farina et al., 2019) because of their familial relationships and context in psychological trauma (Isobel et al., 2019). The symptoms of complex trauma are usually polymorphous; thus, the treatment can also involve more than one psychological modality. This paper discusses the causes of complex trauma, the short-term effects, the long-term effects, available treatments, and the biblical perspective of complex trauma.
Causes of Complex Trauma
The causes of complex trauma are varied, but the baseline remains the repetition of the occurrence of the traumatic events. Child maltreatment has been recognized as the main etiology of complex trauma in children. Other causes such as domestic violence or witnessing domestic violence, child welfare system, bullying, ethnic cleansing, interpersonal violence, immigration, and wars have been implicated in complex trauma in children. Among adults, terms such as tragedy, adversity, stress, and trauma have been used in cases of repetitive psychological and physically traumatic experiences. While the intentions of these events may make them appear as a normal occurrence in life, the outcomes may be devastating even through the youthful and adult life. Trauma has seen the psychophysical experience. This may happen even in the absence of direct bodily harm from the event. The causes of complex trauma may not necessarily harm the individual’s body directly to be considered traumatic events.
The world health organization recognizes child maltreatment as the major cause of childhood trauma. Its main aspects include child physical abuse, sexual abuse, child neglect, and emotional abuse. Child abuse forms a vicious cycle in the development of complex trauma. For example, children cry as the only method to convey their needs physically. In poor childcare situations, they are psychically assaulted because of poor interpretation of their crying, leading to physical trauma as usually seen in child abuse (Saint Arnault & Sinko, 2019). This repetitive cycle goes unnoticed in the immediate period. However, this is when these children should develop associations, attachments, and growth. Prolonged recurrent episodes of abuse impact their immediate and long-term health.
Child neglect as a form of child maltreatment also contributes to complex trauma. In child neglect, the caregiver fails to meet the child’s emotional or physical needs. Children have emotional needs that facilitate their development of attachment and behavior. Failure to meet these needs impacts the development of cognition, behavior, and brain neurobiology. Therefore, their emotional health and forming necessary developmental attachments are disrupted (Bartlett et al., 2018). The relationship between the child and the caregiver and the child’s age play important roles in the development of the sequelae of the complex trauma. The caregiver may assume child neglect because of no apparent consequences at the time of the trauma, thus the propensity to develop complex trauma outcomes.
Sexual abuse is another form of child maltreatment that goes unreported or unnoticed in the immediate or long term. Child sexual abuse exposes the child to traumatic sexual experiences that have consequences on the sexual life. Most cases of child sexual abuse are repetitive due to the fear of exposure of the perpetrators or the child’s fear of the consequences of these acts. Child sexual abuse perpetrators are usually caregivers or close relatives. These are people these children trust with their safety and care but end up betraying them and inflicting repeated traumatic experiences.
Children find it difficult to express these experiences to the community because immediate caregivers will underreport to prevent revealing their social weaknesses (Saint Arnault & Sinko, 2019). Therefore, the victims of child sexual abuse will find no one to trust and report their feelings and experiences about these acts. This situation leads to repetition of the trauma, and its prolonged nature will lead to complex trauma. Children with epileptic disorders are also at risk of experiencing child sexual abuse because of the medical condition that places them in a helpless situation during the episodes. Individuals with mental retardation or handicap who have no mental capacity to decide for themselves regarding sexual matters may be abused because the perpetrators may take that advantage. Most children and adolescent victims of child sexual abuse are usually female and lack adequate caregiver support. Sometimes, child sexual abuse may present with a history of physical abuse or child neglect that has been described to have implantation in complex trauma.
Child sexual abuse is very broad and can be classified as contact sexual abuse and non-contact sexual abuse. Most of the time, people may think that child sexual abuse involves a huge deviant man who is poorly dressed and unemployed who sexually abuses the children. However, the abusers may be right in the child’s closest surroundings. Contact sexual abuse is thought to be more implicated in the consequences of complex trauma. The contact child sexual abuse activities can include forcing the child to undress, having sexual contact with the child, forcing the child to touch another person sexually, and non-penetrative sexual acts. Non-contact sexual abuse includes but is not limited to child pornography exposure, exposing the child’s genitalia, and forcing the child to participate in sexual conversations. Some of these activities may be thought to have low or no impact on the child, while in a real sense, they significantly impact the way the child feels and attaches to the environment and their future (Davis, 2021). This makes their risk of repetitiveness and prolongation to be high.
Interpersonal adversities have also been implicated in the development of complex trauma. Children may suffer from separation and emotional instability in the child welfare system and foster care. Paradoxically, children should feel better in the child welfare home systems. However, some children will feel trapped in these systems or distant from their previous caregivers. The repeated traumatization also contributes to complex trauma because it is a prolonged situation with traumatic components. Bartlett et al. (2018) reported that children in the child welfare system are more likely to require mental health services due to trauma and related consequences than other children.
The environment plays a vital role in preventing the child from traumatic experiences. However, it also predisposes the child to trauma of varied consequences. Witnessing domestic violence impacts the child’s growth. The presence of both parents may provide the child with a sense of security. This is augmented by the lack of disputes and violence between these caregivers. Constant quarrels between the parents of the substituting caregivers deny them the opportunity to bond and associate with the environment and people. Domestic violence may come in the form of physical fights, verbal altercations, or a lack of harmony between the parents or caregivers. Civil and clan wars also deprive the children of a sense of security. While in most cases, war encounters might be a one-off event, is other situations such as places prone to clashes, tribal or civil, predispose the children to repeated witnessing of traumatic events.
Symptoms of Complex Trauma
The relationship between trauma and psychological pathologies was established more than a century ago. The repeated occurrence of trauma presents additional dimensions of psychological and behavioral presentations besides post-traumatic stress disorder. Complex trauma presents devastating consequences to the child because of the interference with the formation of secure attachments and social bonding. Complex trauma causes impairments in the various dimension of psychology and physiology. These impairments include but are not limited to biological impairments, impairments in cognition, behavior, attachments, regulation of affect, and self-concept (Bartlett et al., 2018). Posttraumatic stress disorder is one of the most commonly described trauma presentations in mental health. PTSD is usually associated with acute and one-off trauma incidents, as seen in automobile accidents, war, and natural disasters. The disorder is most commonly associated with complex post-traumatic stress disorder.
Complex Post-Traumatic Stress Disorder
The usual post-traumatic stress disorder is majorly described with hyper-avoidance, hyperarousal, negative mood and cognition alterations, and distressing memories and dissociations. These symptoms are accompanied by evidence of event(s) in the past that are remotely translated as traumatic events. Complex PTSD is closely related to a DSM-5 recognized disorder complex psychological trauma and some literature items use these terms interchangeably. In complex PTSD, there should be evidence, reported or inferred, of prolonged and repetitive traumatic stressors (Barbieri et al., 2019). There should also be a temporal sequence between the traumatic stressors and the resultant harm, neglect, or abandonment in the individual’s life. These events are always encountered during the individual’s vulnerable stages of development, usually childhood and early adolescence. Therefore, the damage is significant to the child’s future psychological and physical presentation.
Complex PTSD is not a DSM-recognized diagnosis but has different treatment from PTSD. It cannot be said with certainty that complex PTSD is similar to complex, but they share various presentation features that make them closely similar in presentations. The inclusion of complex PTSD is to e included in the ICD-11 but complex trauma diagnosis and inclusion is still under various scholarly debates due to variations in psychiatric schools of thought. The complexity in the diagnosis of complex trauma makes it difficult to describe in comparison with posttraumatic stress disorder. Other alterations, later described, are sued to diagnose complex trauma.
Normal body and brain responses to trauma include a return to the normal state following the stress response. The biology of emotional regulation and stress response in the neurobiological constitution in the brain. Children exposed to complex trauma have difficulty maintaining the normal regulations. Normal regulations are important inadequate brain development. Therefore, exposure to complex trauma reduces the brain development capacity in these children. Integration of the interhemispheric functions is also impaired. The victims of complex trauma will be susceptible to stress because they have difficulties in controlling their arousal and thus poor attention focus. Brain cognitive and behavioral development is even faster in late childhood and adolescence. During this developmental stage, children form social and interpersonal relationships. This development enables them to solve problems without abnormal reactions, emotional or physical. Impairments in the development of interpersonal relationships lead to difficulties in behavior regulations.
Abnormal Regulation of Affect
The aforementioned biological capacity impairments impact the victim’s affect and emotions. Complex trauma in the crucial development stages interferes with the registration of appropriate emotions during growth. During normal development, the child should identify and register all emotional reactions from their immediate caregivers and label these reactions as appropriate. The child needs to express their emotions safely following normal registration and interpretation. In complex trauma, this process is interfered with such that the consistency in registrations and identification is not ensured. These children may show dysphoria, avoidance or emotional situations, numbing of emotions, and maladaptation. For example, a complexly traumatized child may accompany rejection with smiling instead of anger or sadness. The inconsistency can explain this reaction to rejection behaviors during a traumatic childhood. In these traumatic situations, the caregiver would be reacting with inappropriate and inconsistent emotions. The child, thus, registered the inappropriate emotional response.
Abnormal Behavioral Regulation
Behavioral patterns are controlled by the brain’s registration of appropriate behaviors during development. Complexly traumatic childhood experiences lead to under-controlling or overcontrolling of behavioral patterns and coping. Learning and controlling behavior usually start as early as the second year of life. Children who have experienced complex trauma will show rigidity in behavior patterns. These children learn through aggression and violence, making them register and understand these methods as the only way to get whatever they want. Therefore, these children develop rigidly controlled behavior patterns such as resistance and defiance to changes in routine and rigid control of food intake. These behaviors affect the long-term outcomes of the victims in adult life.
Dissociation can be loosely defined as inability or failure to integrate information and experiences. Complex trauma in children leads to the disconnection seen in thoughts and emotions. This is different from the abnormal regulation of affect that only dealt with the emotional response. In complex trauma, the victims show the disconnect between conscious awareness and their physical sensation, planning, and self-awareness. Their perception of the environment does not match their thought processes or actions. This is related to the body’s coping mechanism in these highly and repeated traumatic situations in complex trauma. The prolonged exposure to complex trauma leads to dissociation as a psychological defense mechanism and protective mechanism. This greatly impacts the presentations mentioned above, such as behavior and affect.
Cognition in children who had undergone complex trauma is sometimes impaired, as shown by lower IQ scores in some prospective studies. Complex trauma interferes with cognitive learning and functioning in children who experience child neglect or abuse. The deprivation in the sensory and emotional domains of development contributes to the delay in cognitive development. Delays in registering receptive and expressive language have been associated with inconsistencies of lack of models from their caregivers to adopt. Child neglect as a form of complect trauma is more likely to cause cognitive developmental delays than other causes of complex trauma aforementioned. Child maltreatment also plays a role in the school academic performance of the children. This has been associated with their lower capacities to initiate propitiate problem-solving skills and show other executive functions.
Poor Relationships and Self Concept
Complex trauma develops between two people in a ‘closed space,’ thus the repetitiveness. Social relationships are usually poor in the family context due to poor attachments and relatabilities with caregivers (Isobel et al., 2019). The traumatic disruptions occur in a closed interpersonal sphere leading to distortion in the interpersonal schemata with no external source of social relations. A child coming back to the same traumatic family is less likely to learn new relationships pr ways of interacting with other people (Van Nieuwenhove & Meganck, 2019). Without proper learning of the concept of self-form the caregivers, these children may fail to develop a model of self-image and concept. These children may see themselves as helpless, inefficient, unlovable, and deficient in the social sphere and competencies. Shame and self-incompetence predicate the concept of the children as they grow.
Effects of Complex Trauma
Complex trauma has impacts in the immediate and long-term periods after the cessation of the traumatic experiences. Few effects are seen in the long term as they usually occur during the child’s crucial developmental stages. The short-term effects cumulatively amount to the development of long-term effects. Long-term effects are typically seen in the youthful and adult years, where deviation from the normal is apparent.
Short Term Effect of Complex Trauma
Every survivor of complex trauma has a different story to tell from their experiences. However, most children would not have the capacity to tell these tales because they did not register what society considers normal thinking and behavior in the first place. The short-term effects are usually biological because the body is under stress to evade the traumatic stressor. Changes in neurobiology are seen as imbalances in brain neurochemistry. Mood changes are witnessed as the child’s psychology attempts to respond or adapt to the trauma and mixed perceptions. In the absence of the traumatic stressor, the brain neurochemistry returns to normal. However, the case of complex trauma does not allow the body to return to normal before a new episode of the stressor. This leads to longer effects of the prolonged repetitive trauma.
Long-Term Effects of Complex Trauma
The long-term consequences can be seen as individual, interpersonal, and developmental. The child’s adaptation to respond to the dysfunctional situation can take various forms depending on the cause of the trauma. Personality disorders and some psychiatric illnesses may accrue for the aforementioned presentation of complex trauma. Oppositional defiant disorder (ODD), attention deficit hyperactivity disorder (ADHD), and antisocial personality disorder are some of the disorders seen in the long term in victims of complex trauma. Oppositional defiant behavior is associated with the rigidity in children’s behavior, while antisocial personality is associated with impulsivity and aggression. Substance use disorders are also seen youthful years of these children as they attempt to cope with the traumatic childhood memory. Victims of sexual abuse may develop risky behaviors in adulthood that may be remotely perceived as promiscuity.
Treatment of Complex Trauma
Management for complex trauma mainly involves psychotherapy. Individual, family, and group psychotherapies have been used to manage adolescents and youths with complex trauma. Some scholars argue that the recommended interventions sued to treat PTSD would suffice in treating complex trauma (Van Nieuwenhove & Meganck, 2019). However, the nature of complex trauma and its presentation differs from the usual PTSD. Counseling psychotherapy remains the most widely used treatment modality for complex trauma. Supportive therapies that have been adopted have included improvement in patient safety and assistance with planning for the future. Trauma-focused cognitive behavioral therapy and exposure therapy are also useful in managing complex trauma. However, they may not fully address the complex nature of complex trauma.
The National Child Traumatic Stress Network (NCTSN) recommends a mixed-method approach with six main components. These strategy components aim to address the symptoms of complex trauma as described and improve the child’s physical and emotional environment. Therefore, adequate assessment is advised before treatment. The NCTSN approach ensures safety, self-regulation, self-reflective information processing, traumatic experience integration, relational engagement, and positive affect enhancement (NCTSN, 2018). In this treatment package, the therapist should ensure that the child’s environment does not make the child feel insecure.
This may involve necessary physical transfer to places where the child will be safer. The second component, self-regulation, the therapist aims to enhance the victim’s capacity to balance response in arousal, affect, and behavior through modulation in counseling. Self-reflection will enable the child to reflect on their past, present, and future through enhancing decision making. In the fourth step, the therapist enables the child to suppress the memories or reminders of the traumatic experiences by finding resolution or transformation for the reminders. In the fifth step, the therapist helps the child develop appropriate attachments, which may involve cognitive methods. Lastly, the therapist instills a sense of self-worth, self-esteem, and overall self-concept.
The bible protects children and rebukes any form of harm against children. Moreover, Jesus loved children. Thus, children are considered a blessing from God. In the book of Ephesian 6:4, the bible says that “Fathers, do not provoke your children to anger, but bring them up in the discipline and instruction of the Lord.” Paul’s letter to Colossians urged fathers to avoid provoking the children as this would discourage them (Colossians 3:21) (King James Bible., 2017). The book of proverbs emphasizes this by explaining that parent should train up their children in good ways so that they will remember it even when they grow old (Proverbs 22:6). The Bible is thus a good source of inspirational teaching enough to enable Christian parents to protect the children and prevent unnecessary trauma that is monodisciplinary from coming upon them.
Summary and Conclusion
Complex trauma is not a DSM-5 resigned diagnosis but has been used in practice because it differs from the normal one-off trauma events associated with PTSD. The key features of this trauma are repetitive, prolonged trauma, usually in the crucial developmental stages of childhood. Child sexual abuse, physical abuse, and child neglect are some of the most common forms of complex trauma. This type of trauma leads to defective behavior, affect, and cognition growth. Treatment is usually through psychotherapy. However, there are still controversies regarding effectiveness.
Post-traumatic stress disorder presents more or less similar to complex trauma symptoms. The major difference is seen in the chronicity of the presentation and nature of causes. CBT has been tried before, but the comparison with the recommended NCTSN method regarding effectiveness and efficacy is still debatable. Further research is, therefore, needed to compare the efficacy between these two modes of treatment. This evidence-based practice will provide necessary insights into the management of complex trauma.
- Barbieri, A., Visco-Comandini, F., Alunni Fegatelli, D., Schepisi, C., Russo, V., Calò, F., Dessì, A., Cannella, G., & Stellacci, A. (2019). Complex trauma, PTSD, and complex PTSD in African refugees. European Journal of Psychotraumatology, 10(1), 1700621. https://doi.org/10.1080/20008198.2019.1700621
- Bartlett, J. D., Griffin, J. L., Spinazzola, J., Fraser, J. G., Noroña, C. R., Bodian, R., Todd, M., Montagna, C., & Barto, B. (2018). The impact of a statewide trauma-informed care initiative in child welfare on the well-being of children and youth with complex trauma. Children and Youth Services Review, 84, 110–117. https://doi.org/10.1016/j.childyouth.2017.11.015
- Davis, S. (2021, April 5). Childhood sexual abuse and complex post-traumatic stress disorder. Cptsdfoundation.Org. Accessed 11th December 2021 from https://cptsdfoundation.org/2021/04/05/childhood-sexual-abuse-and-complex-post-traumatic-stress-disorder/
- Dye, H. (2018). The impact and long-term effects of childhood trauma. Journal of Human Behavior in the Social Environment, 28(3), 381–392. https://doi.org/10.1080/10911359.2018.1435328
- Farina, B., Liotti, M., & Imperatori, C. (2019). The role of attachment trauma and disintegrative pathogenic processes in the traumatic-dissociative dimension. Frontiers in Psychology, 10, 933. https://doi.org/10.3389/fpsyg.2019.00933
- Isobel, S., Goodyear, M., & Foster, K. (2019). Psychological trauma in the context of familial relationships: A concept analysis. Trauma, Violence & Abuse, 20(4), 549–559. https://doi.org/10.1177/1524838017726424
- King James Bible. (2017). King James Bible. Online. https://www.kingjamesbibleonline.org/ (Original work published 1769)
- NCTSN. (2018, March 5). What is complex trauma: A resource guide for youth and those who care about them. Nctsn.Org. Accessed 11th December 2021 from https://www.nctsn.org/resources/what-complex-trauma-resource-guide-youth-and-those-who-care-about-them
- Saint Arnault, D., & Sinko, L. (2019). Hope and Fulfillment after complex trauma: Using mixed methods to understand healing. Frontiers in Psychology, 10, 2061. https://doi.org/10.3389/fpsyg.2019.02061
- Van Nieuwenhove, K., & Meganck, R. (2019). Interpersonal features in complex trauma etiology, consequences, and treatment: A literature review. Journal of Aggression, Maltreatment & Trauma, 28(8), 903–928. https://doi.org/10.1080/10926771.2017.1405316