Developmental Couple Therapy for Complex Trauma

A Manual for Therapists

Heather B. MacIntosh

• Editorial: Routledge
• Año: 2019
• ISBN:
  9781351811194
• Edición: 1
• Categoría: Psychology
• Categoría: Psychotherapy

Developmental Couple Therapy for Complex Trauma provides therapists with comprehensive and practical guidance for integrating DCTCT into their work with traumatized couples. The book includes an evidence-based framework which emphasizes the importance of containing conflict and helps clients to build emotional regulation and mentalizing skills. The framework is an invaluable asset to all clinicians working with couples dealing with the ravaging impacts of complex trauma, who may not be able to benefit from traditional forms of couple therapy due to challenges in regulating emotions, mentalizing and other aspects of the complex trauma response that limit capacity to engage in relationships and couple therapy.

The chapters guide you through the four key stages of DCTCT: Psychoeducation, Building Capacity, Dyadic Processing, and Consolidation. Each stage has accompanying activities and narratives in which to engage traumatized couples and includes a variety of case transcripts to illustrate the approach. Throughout the manual the author provides the reader with:

• insights from real-world scenarios based on her extensive clinical experience;

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• worksheets that can be used as part of the therapeutic process;

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• systematic analyses of the therapeutic process from the therapist's point of view;

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• comprehensive recommendations for further reading so that you can develop your expertise in any area of DCTCT.

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Never losing sight of the fact that the therapist plays an essential role as a coach and mentor for those undertaking couple therapy, this manual is a valuable tool for any clinician working to engage traumatized couples and equip them with the skills they need to develop and maintain a strong and vibrant couple relationship.

Chapter 1

Introduction for therapists

By the time I was 22 years old, I had two young children, my marriage was crumbling beneath me, and feelings, images, sounds, and sensations were intruding on me, night and day, overwhelming me. I was forced to come to grips with the loss of my intended career as a classical singer as the long-term effects of an early traumatic injury began making themselves known in my body and mind. I had no other identity than that of a singer, no family, and no relationships that could help me buffer against the tsunami of converging forces that thrust themselves on me as I navigated motherhood without a model of what a mother should be. I didn’t understand what was happening to me. I didn’t know how to exist haunted by constant terror, but I was desperate to provide my children with a childhood different from my experience in my adoptive family. In that environment, shame was served up liberally as a side dish with every meal, while sexual boundaries only existed to protect the “real” family. Meanwhile, as the adopted child, I was fair prey for stray desires and wandering bodies. So I got out of bed every morning and put one foot in front of the other, trying to be the mother I had never experienced, myself. I had no way to afford good therapy, but someone suggested I read an article by Bessel van der Kolk, “The Body Keeps the Score” (van der Kolk, 1994). I began to understand what was happening to me, albeit in an entirely intellectual, cognitive way. I began to make sense of my experience: the words on the page contained my experience and gathered me up into meaning. This marked the beginning of a lifelong journey to understand the impacts of trauma and to help survivors fight their way out of the paper bag of their lonely terrors. The more I came to “know” about trauma, the clearer it became to me that the “knowing” wasn’t enough. As much as I longed for love and connection, I was still unable to wrest myself free of the avoidance that had caught hold of me in the bid for survival in a family of emotional and sexual intrusions. I began to learn of the powerful disconnection between insight and experiential change; simply understanding something doesn’t help you change it when it is driven by forces that exist outside of one’s awareness. While I understood the impacts of my own trauma on my capacity to connect with others, I was not able to change the feeling that I needed to pull away as soon as anyone got close to me. Over many years of education, a million hours of therapy, and an extended practice of intellectual containment, I found my way into a relationship with a woman who had a healthy capacity to tolerate my needs to manage our level of closeness, combined with just enough pursuit to be the glue in our relationship. That was over 20 years ago; over those years I have been living the parallel process of learning how to tolerate being close, loving, and being loved, while also working on developing ways to work with survivors who are struggling in their longed-for but distressed relationships. This book reflects that journey, the journey of one survivor struggling to balance her longing for love with her terror of connection and the journey of a clinician researcher working to help couples brave the pain and vulnerability of bridging the gap between their desire and their terror, to build loving relationships of hope and healing. I hope that, in these pages, you may find some answers to your questions about how to work with these challenging couples who want so much to be freed from the pull of the past living in the present, and encouragement for your persistence and commitment to this difficult but vitally important work.

Why is this manual needed?

Childhood trauma can fracture the basic fabric of human relationships. When children are harmed, especially by those in positions of trust, they may later struggle with developing and maintaining strong, stable, and loving relationships in adulthood. For survivors of childhood trauma, the difficulties that arise from their traumatic experiences are not just those related to the after-effects of trauma that might befall an adult who had been traumatized, such as flashbacks, nightmares, and avoidance of reminders of the trauma; they are more complex. These more complex trauma responses are those that interfere with the web of human relatedness, trust, safety, and the skills that help a person develop and maintain a relationship with a primary attachment figure (Herman, 1992). In spite of these challenges, survivors of childhood trauma continue to long for an attachment relationship that is not fraught with fear and pain but rather is loving, gentle, safe, and secure.

What is it that fuels the longing of childhood trauma survivors to find people to love them, and to love in return, in the face of remembered traumas often inflicted by the very people who should have been protecting them? I reflect on this question every time I sit with a couple that seeks intimacy and security yet struggles to navigate the consequences of devastating childhood attachment relationships and violent, destructive traumas. What is it that defies the lesson of history – people are dangerous – and allows them to try, against the odds, to find love? There is no easy answer to this question, but I am awed by the forces that drive attachment as a basic, primal, human need. And so, therapists who sit with these couples need to find ways to help balance the forward momentum of attachment seeking with the backwards-leaning terror and power of destructive models about how to be in relationships.

Traditional models of couple therapy provide practitioners with important skills to intervene with couples, but inherent in these interventions is the baseline assumption that partners in these couples possess the basic skills of interpersonal engagement, the developmental self-capacities, with which to tolerate, engage in, and benefit from the therapy. For many of the couples with whom I work, these basic developmental capacities are simply not present; all efforts to engage in the give and take, the ebb and emotional flow of couple therapy lead to crisis, emotional escalation, and in some cases, interpersonal violence and dramatic relationship ruptures. The goal of Developmental Couple Therapy for Complex Trauma (DCTCT) is to provide competent, effective care to couples poorly equipped to engage in traditional couple therapy. This model takes a developmental, step-by-step approach to building skills in the couple context, focusing on containment and growth while preparing the couple for the later “meat and potatoes” of stages focused on healing and processing trauma.

Why couple therapy?

While we know that couple relationships may moderate the impact of childhood trauma, clinical research over the past 30 years has concentrated on the development and validation of individual models of treatment for childhood trauma survivors. In fact, until very recently, couple therapists would turn away trauma survivor couples under the premise that survivors should engage in individual therapy prior to embarking on couple therapy. It was believed that following extensive individual treatment, trauma survivors could be “healed enough” and ready to shift their focus away from themselves and towards their partner and the couple relationship. It has also been suggested that couple therapy with childhood trauma survivors in active healing would be too tumultuous and chaotic to be safe and productive. What then happens to these couple relationships while waiting, potentially for years, for the survivor to be “healed enough”, and how could that determination be made?

Emerging into adult couple relationships, childhood trauma survivors often evidence insecure attachment styles and display fearful avoidant ways of being with their partners, leading to painful struggles with maintaining closeness and potentially intolerable conflict (Alexander, 2009; Cloitre, Stovall-McClough, Zorbas, & Charuvastra, 2008). When survivors do develop and maintain relationships, they are often plagued with distress, interpersonal violence, severe difficulties with communication, and significant struggles in their sexual relationships. The dance of connection is often characterized by competing and fluctuating needs for closeness alternating with avoidance, typical of fearful avoidant attachment styles (DiLillo, 2001; Godbout, Runtz, MacIntosh, & Briere, 2013; Rumstein-McKean & Hunsley, 2001). Survivors’ relationships are often full of the pain of longing for connection contaminated with the terror of intimacy and closeness.

For partners, being in a relationship with a childhood trauma survivor can be challenging. Partners report isolation, pain, anger, frustration, challenges with communication and intimacy, sexual difficulties, and general dissatisfaction (Reid, Wampler, & Taylor, 1996). Partners talk about feeling as though they need to shut down emotionally and they tend to make negative assumptions about their survivor partners and their relationships (Millwood, 2011). Partners also report feeling left out of the individual therapy process, and they complain that individual therapists do not help the trauma survivor with important relational issues such as developing intimacy and repairing sexuality. Many partners voice the fear of becoming associated with their partners’ perpetrator when they express their sexual needs or more difficult emotions. Partners often end up feeling that they are waiting for their turn – when the individual therapy has come to an end – so that they can resume their relationship (Dimitrova et al., 2010; Runtz & Schallow, 1997; Whiffen, Judd, & Aube, 1999).

When asked, childhood trauma survivors also perceive their partners in a negative light. They see them as less caring or supportive, and more controlling, insecure, dependent, immature, and exploitative, compared to the way partners without a history of childhood trauma describe their significant others (DiLillo, 2001).

What is known about working with childhood trauma couples?

The literature about working with childhood trauma survivors in couple therapy has begun to grow, as more survivors seek support in their relationships and express dissatisfaction with therapists’ limited understanding of the role of trauma in relationship distress (Zala, 2012). Up to one third of couples presenting for couple therapy have a history of childhood sexual abuse in one or both partners (Anderson & Miller, 2006). Meanwhile, the process of couple therapy with childhood trauma survivors can be extremely challenging. Adding an attachment figure to the therapy process can accentuate survivors’ challenges with attachment insecurity, emotion regulation, and tolerating or even imagining their partner’s perspective. In my research, the most challenging moments in couple therapy were those where one partner expressed a need for something from their partner or a hurt that was caused by their partner: traumatized partners had difficulty listening, hearing, and responding to what their partner needed to some extent without becoming defensive or overwhelmed with difficult emotions (MacIntosh, 2013; MacIntosh & Johnson, 2008). Our analyses of the process of couple therapy with childhood trauma survivors have established key developmental self-capacities – attachment security, emotion regulation, and perspective taking or, more broadly, mentalizing capacities – which were severely compromised in childhood trauma survivor partners. The compromise of these capacities appeared to play a vital role in the capacity of the survivor to tolerate and fully engage in the couple therapy process.

Why address developmental issues in childhood trauma couples?

Challenges with emotion regulation and mentalization are thought to underlie many of the difficulties that childhood trauma survivors experience in their couple relationships and in couple therapy. For children to develop the capacity to regulate their emotions, they need to experience the help of an attachment figure when dealing with distressing emotional states in early years. Over time, the help they receive from caregivers within secure attachment bonds becomes internalized as a self-capacity they will retain throughout their lives (Sroufe, 1996). Otherwise, distress becomes intolerable for infants and young children, and they do not develop the capacity to regulate their emotional distress. Lost in the sea of their own distress, without attachment figures to regulate and soothe them, these survivors may eventually turn to self-injury, dissociation, alcohol, sexual compulsivity, eating disorders, and other impulsive or self-destructive behaviours to distract, soothe, and numb themselves from their tumultuous inner worlds (Briere, 2006; Cloitre, Cohen, & Koenen, 2006; Linehan, 1993; van der Kolk, 1996; Zlotnick et al., 2003). Childhood trauma survivors can experience severe challenges with emotion regulation, even more than those who experience trauma in adulthood (Pelcovitz et al., 1997). For survivors, these problems can manifest in the form of emotional distress arising from seemingly small stresses, severe emotional responses, and subsequent difficulty calming down and letting go of upsetting events (Cloitre, 2002; Rorty & Yager, 1996; Zlotnick et al., 1999). Imagine the struggle, then, when survivors face the complex emotional challenges of romantic relationships without access to these vital capacities to regulate their own emotional states. Couples have described their emotional lives together as chaotic, frightening, painful, and exceedingly frustrating, as an experience of never being able to get out of the dark woods, no matter what direction they take.

Mentalizing is an interrelated self-capacity, a form of imaginative mental activity to make sense of others and of ourselves through the understanding of mental states. These capacities allow us to infer meaning to both explicit and implicit mental processes. Mentalizing is connected to emotion regulation; this capacity also develops throughout infancy and early childhood in the context of attachment relationships with those close to us. Caregivers who are responsive and try to understand our needs and distress help us develop the capacity to mentalize. They understand when it is time to help a person to become calm, soothed, and settled and when it is time to play, roughhouse, and laugh. Throughout these experiences, children learn that their feelings and mental states are their own and are acceptable, tolerable, and understandable. In learning how to mentalize well, they begin to think about, reflect on, hold, and explore emotions, thoughts, and mental states. Strong mentalizing capacities are fundamental to a person’s ability to navigate the social world.

Survivors of childhood trauma frequently have difficulty in mentalizing well (Fonagy, 2010; Stein & Allen, 2007). Early studies have identified associations between childhood adversity and mentalizing difficulties in adulthood (Fonagy et al., 1996; Stein, Fonagy, Wheat, Kipp, & Gerber, 2004). In addition, mentalizing may play an important role as a mediating factor between childhood trauma and later psychological and relational functioning (MacIntosh, 2013). In general, those who report higher levels of abuse in childhood tend to have lower mentalizing capacities. In addition, those who experienced childhood trauma yet subsequently developed mentalizing capacities appeared to experience lower levels of distress, and difficulties in functioning, in adulthood. For survivors in couple relationships, it seems that mentalizing acts as a buffer against the development of some of the problems that traumatized couples experience in managing conflict and closeness (Fonagy et al., 1996). Thinking about how mentalizing capacities develop, through the consistent and responsive interchange between children and their attachment figures, it makes sense that survivors of childhood trauma often struggle in this area; someone who abuses a child is clearly unable or unwilling to imagine that child’s inner experience. What child would feel safe and curious about the inner contents of the mind of someone who would abuse them?

At the same time, mentalizing is a capacity essential for partners to develop and maintain a healthy romantic relationship. Without being able to tolerate and reflect upon one’s own thoughts, feelings, and behaviours, and those of one’s partner, being in a couple relationship is very difficult indeed. Mentalizing allows us to acknowledge and take responsibility for ourselves in relationships, to have empathy and compassion for one another, to be vulnerable and open, and to have safe and clear boundaries with partners. However, old patterns, including those set by abusers, are likely to arise in intimate relationships that call on our most basic fears, longings, hopes, and needs. These patterns are often outside of our awareness. For childhood trauma survivors, who may previously have missed the opportunity to develop these vital self-capacities, emotion regulation and mentalizing – navigating the emotional complexities of relational life – can be a daunting task. But grounded in a therapeutic attachment that provides a safe base for exploration, a couple dealing with the ravages of scars left by childhood trauma may begin to engage in the emotionally challenging process of repairing and strengthening their couple relationship.

What is Developmental Couple Therapy for Complex Trauma?

Developmental Couple Therapy for Complex Trauma (DCTCT) was developed to provide couples dealing with the impacts of childhood trauma with a form of therapy that integrates a specific focus on the development of attachment security, emotion regulation, and mentalizing skills within the couple therapy context. The educational and skills-based focus early in the process allows couples to be prepared for, to tolerate, and then to fully engage in the deeper work of trauma processing and resolution of couple distress characteristic of later stages. This manual provides you, the therapist, with a basic framework with which to approach this work. Each section provides information for you, for your own knowledge development, along with a general outline of tasks and goals accompanied by segments of clinical sessions to illustrate them.

How the manual is organized

This manual is organized based on a model built to reflect the work I have done with couples in clinical settings. As with all manualized treatments that outline interventions in stages and steps, all couples differ, and each of them will require a unique approach that might involve more or less time at each stage. Many couples will have the capacity to tolerate difficult conversations right from the beginning of the process; meanwhile, others require many months of gentle preparation and relationship building before becoming ready to dive into conversations about traumatic memories, triggers, sex, and the role of past traumas on current relationship distress and conflict. Be mindful not to undermine the remarkable resiliency of survivor couples. Review each section and move at the pace of the couple’s capacities.

Moving through the manual, you will find that early chapters, in Stage One, focus on providing the background and resources needed to engage in the psychoeducational modules. These provide a kind of buffet that allows you to adjust your selection of psychoeducation and interventions to the specific needs of each couple. Some couples may need to dive right into sex and sexuality, while other couples may need to focus on the impact of trauma on individuals and couples for many weeks before other topics can be explored. Each module of this section will be accompanied by psychoeducational handouts to help you explore these themes with clients. Moving into later stages of treatment, the manual will provide you with appropriate background, suggesting readings to expand upon particular topics and transcriptions of sessions that demonstrate how to get into the moment-by-moment process with a couple.

As a DCTCT therapist, your work changes during the successive stages of treatment. Beginning as a teacher, model, and mediator, then becoming a containing trauma therapist at certain intermediate stages, practitioners eventually act as a couple therapist, coach, and validator during the later stages. Over the recommended course of treatment, sessions move from weekly to bi-weekly to monthly and then taper off after 6–8 months. It is essential that couples not feel that their success in couple therapy is tied to losing you as their therapist. Go slowly, help them pull out of challenges and double back for more consolidation when they find applying their new skills and abilities to be too difficult, and cheer them on as they move towards autonomy.