“There is no growth without real feeling. Children not loved for who they are do not learn how to love themselves. Their growth is an exercise in pleasing others, not in expanding through experience. As adults, they must learn to nurture their own lost child.” — Marion Woodman. Last year, I wrote an article about child abuse , specifically dispelling the notion that child abuse is “just” physical in nature. I wrote about how child abuse can also look emotional, psychological, verbal and/or neglectful in nature and provided examples of what this can look like. In today’s post, I want to introduce an idea of what can result from the complexity of this child abuse, particularly if the abuse takes place over a period of time and in the context of a relationship with a parent or guardian. This idea is called complex relational trauma and it can be deeply impactful to children and the adults they become. I want to provide a brief overview of what complex relational trauma is, how it happens, what the symptoms and impacts of this may be, and share a curated list of resources you may want to explore further if you identify with complex relational trauma. What is complex relational trauma? “Unlike other forms of psychological disorders, the core issue in trauma is reality.” ― Bessel A. van der Kolk. First, let me be clear that complex relational trauma is not an official diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (the DSM, the clinical guidebook of the mental health community). Complex relational trauma and its attendant symptoms do, however, most closely resemble post-traumatic stress disorder (PTSD) which is in the DSM. However, complex relational trauma could and sometimes is also interchanged with terms and descriptions such as complex PTSD, developmental trauma and interpersonal trauma. So, why is complex relational trauma not in the DSM? There are likely many explanations but one I personally and professionally believe is that the DSM — while valuable — sometimes fails to take into account our full spectrum of humanity and complicated relational experiences and, thus, lacks in some ways. So, for the sake of this article, I’ll use the term complex relational trauma, explain it anecdotally (since an official diagnosis is lacking) and provide the symptoms that most closely resemble PTSD as well as what I’ve seen and understood clinically. So again, what is complex relational trauma? Complex relational trauma is likely to happen in our primary relationships with parents, caregivers, guardians or those with authority and great control over us (for example, the head of a boarding school or director of an orphanage) where there is accessibility to the child or teen, and a level of dependency from the victim to the abuser. Complex relational trauma happens more than once and usually over a period of time, making it also, usually, cumulative. For example, complex relational trauma doesn’t have to end in childhood; there can be the same or different perpetrators such as going from having your father be the abuser to having a string of abusive relationships with men. Complex relational trauma is, effectively, anything that undermines, demeans or erodes the dignity, safety and well-being of the individual who goes through it. Examples of events that can lead to complex relational trauma can include the scenarios from my prior article and it can also include experiences with caregivers or guardians that are fundamentally chaotic, unstable, unsafe, inconsistent, unpredictable and overwhelming. Exposure to domestic violence, having neglectful, apathetic, or emotionally unavailable caretakers, parents who betray you or fail to advocate for you and your needs, parents with mental illness, being parented by a narcissist or with addictions, etc. All of these are examples of who and what can contribute to the development of complex relational trauma in a child and adult. But what makes these relational experiences traumatic? The bottom line is this: when children experience traumas and stress, it is not necessarily the trauma itself that becomes the problem. If a child has securely attached, attuned, loving, consistent caregivers who can support them in metabolizing the stress, organizing and making sense of it, the child can more or less move through a trauma or stressor functionally. However, if the trauma or stressor is happening within the attachment relationship with the parent or guardian, the child, therefore, cannot usually rely on the adult to help them integrate and process the stress. Or if the trauma or stress happens outside of the attachment relationship but the caregiving adult still fails to support the child in managing, healing or recovering from it, a child will likely develop maladaptive and compensatory responses to organize their experience simply because, as children, they do not have the resources and coping skills to do much else. Maladaptive responses are numerous and varied but essentially, if left unaddressed and untreated, they can lead the child to become an adult who has ineffective beliefs and behaviors about themselves, about others and about the world. So, what specifically can these maladaptive beliefs and behaviors look like? Impacts on the individual who goes through complex relational trauma. “As the ACE study has shown, child abuse and neglect is the single most preventable cause of mental illness, the single most common cause of drug and alcohol abuse, and a significant contributor to leading causes of death such as diabetes , heart disease, cancer , stroke and suicide .” ― Bessel A. van der Kolk . The impacts of complex relational trauma will be wide, varied and unique to the individual who experiences it. There is no one-size-fits-all description. It’s absolutely possible that two children, growing up in the same household where the relational trauma took place, will have wildly different responses due to many factors including but not limited to the child’s temperament and resources, length and intensity of exposure to the trauma, the type of trauma and any if at all support in managing it, etc. So, all of this to say that while there is no one recipe for what the impacts of complex relational trauma may be on an individual, there is, according to the symptoms in the DSM diagnosis of post-traumatic stress disorder (PTSD), and what I have experienced and understood clinically, a list of possible and probable outcomes: 1. Attachment wounds and development of an attachment style that is other than secure (see my forthcoming blog post for more on this); 2. Cognitive distortions (erroneous or non-constructive beliefs about self, others and the world) and/or intrusive thoughts; 3. Avoidance behaviors to minimize contact or recreation of the events or scenarios that caused the distress; 4. Dissociation, an inability to recall the traumas or to stay mentally present when reflecting on and discussing them; 5. Somatic impacts such a hyperaroused nervous system, muscle tightness, trouble sleeping or other uncomfortable body sensations; 6. Interpersonal difficulties in romantic relationships, at work, with friends, with neighbors, with the family of origin, feeling detached and separate from others; 7. Comorbid (meaning co-occurring) disorders such as eating disorders , substance disorders, compulsive behavioral patterns, self-harming behaviors, possible development of a personality disorder or mood disorder; 8. Emotional distress and dysregulation challenges (either too much access or too little access to emotion and difficulties appropriately expressing this emotion); 9. Life task impairments such as holding down a job, creating stable housing, managing money well, achieving relational, academic and professional developmental milestones, etc. And while this list is not exhaustive, you can see that the impacts of complex relational trauma effectively can impair nearly every major life area. Often, this is how life for a complex relational trauma survivor feels: fragmented, broken, splintered and not whole across so many different life areas… Now, as challenging as it can be to begin recovering from a childhood of complex relational trauma, I do personally and professionally think it is possible and that it is one of the most worthwhile journeys anyone could ever make. In essence, it’s a journey to reclaim your life, to take the little fragments and make something beautiful and more whole from them. Healing from complex relational trauma. “As long as you keep secrets and suppress information, you are fundamentally at war with yourself… The critical issue is allowing yourself to know what you know. That takes an enormous amount of courage.” ― Bessel A. van der Kolk. For individuals dealing with complex relational trauma and the clinicians who work with them, it can, quite frankly, sometimes be hard to identify and understand that what you are dealing with is a trauma history. So many of the clustered symptoms of complex relational trauma overlap with mood and personality disorders and may even be missed if a comorbid disorder (like bulimia nervosa or panic disorder ) exists, or if a trauma background is not identified by either party. It’s important if you think that you see yourself in this article or in this concept of complex relational trauma, to talk to your therapist about it. When we shine a light on things as they really are, it gives us a better chance to work with them. That is because in recovering from complex relational trauma, there is plenty of work to be done. Recovery is and will be, for many, multidimensional work as the wounding itself is multidimensional. There’s the relational wounding component and the need for relational healing which, I believe, can happen in the context of a safe, supportive, attuned and reparative experience with a trained professional ( like a therapist ) or with a dear friend or securely attached romantic partner. There is the somatic level of the work, the need to regulate and retrain the nervous system and body that the world is safe and to help it calm down and respond appropriately versus in default. There is the cognitive level of the work which includes recalling, narrating, and making meaning and sense of memories and history as well as forming and internalizing newer, more constructive beliefs about oneself, others, and the world. There is the emotional level of the work, learning or relearning emotional regulation, emotional expression, even being able to identify emotions in the body. And there is, I believe, life skills work that may have been missed or impeded by the complexity of the relational trauma. Work like managing money wisely, seeking out and nurturing a career, practicing self-supporting hygiene and personal care habits, and learning the myriad complex logistical skills that can lead to a whole and fulfilled life. The best way, I truly believe, to begin recovering from complex relational trauma is to seek out professional support, ideally with a clinician who is well-versed in trauma. I also believe that psychoeducation can be a wonderful and helpful tool in the recovery process and so, to that end, I have included some curated resources for you below. Resources on complex relational trauma: “First, the physiological symptoms of post-traumatic stress disorder have been brought within manageable limits. Second, the person is able to bear the feelings associated with traumatic memories. Third, the person has authority over her memories; she can elect both to remember the trauma and to put memory aside. Fourth, the memory of the traumatic event is a coherent narrative, linked with feeling. Fifth, the person’s damaged self-esteem has been restored. Sixth, the person’s important relationships have been reestablished. Seventh and finally, the person has reconstructed a coherent system of meaning and belief that encompasses the story of trauma.” ― Judith Lewis Herman. I want to thank my friend Carol Anna McBride, creator of The Trauma Project , for her recommendations of resources to further explore the topic of complex relational trauma. I will add, too, that The Trauma Project itself is an excellent resource for anyone who has undergone complex relational trauma and is seeking education, support and community around it. Treatment of Complex Trauma: A Sequenced, Relationship-Based Approach by Christine Courtois and Julian Ford. Journey Through Trauma: A Trail Guide to the 5-Phase Cycle of Healing Repeated Trauma by Gretchen Schmelzer, Ph.D. The Complex PTSD Workbook: A Mind-Body Approach to Regaining Emotional Control and Becoming Whole by Arielle Schwartz, Ph.D. The Body Keeps Score: Brain, Mind, And Body In The Healing Of Trauma by Bessel van der Kolk. Other articles of mine that may complement this one in your recovery from complex relational trauma: Dispelling myth of child abuse. How to recover from growing up with a narcissistic parent. The playing field wasn’t level to begin with: on childhood trauma and the fruitless comparison game. The power of being the black sheep in your family. What does it mean to remother yourself and why is it so critical for our growth as women? The five healing tasks of the un- and under-parented. Yes, sweetheart. You do actually get to grieve this. Moving forward. “She could never go back and make some of the details pretty. All she could do was move forward and make the whole beautiful.” — Terri St. Cloud. I include the above quote often in my writing often because, fundamentally, this describes my orientation and belief about therapy and therapeutic work. Our past is not something we “just get over,” nor is it something we can ignore. Our past is something which, when ready and with support, we turn towards and face, and only then can we do the grieving and healing work we need to do in order to move forward and make the whole of our lives more beautiful than our pasts have been. Confronting our personal history takes tremendous courage, but it is so, so worth it. Now I would love to hear from you in the comments below: Have you heard of the term “complex relational trauma” before? Do you see yourself in this? What or who has been a support to you in your healing journey in recovering from complex relational trauma? Leave a message in the comments below so our community of readers can benefit from your wisdom. And until next time, take very good care of yourself. Warmly, Annie.