Complex Client

Jeremy, a 28-year-old commodities trader, enters therapy with the presenting problem that, “I can never seem to maintain an intimate relationship.” Initially, Jeremy’s focus is solely on his struggles with romance, but closer questioning reveals that his friendships and business relationships are also mostly short-lived, and even his family ties run hot and cold. A full assessment shows he has a disorganized attachment style that probably developed, as attachment styles typically do, during infancy and early childhood. Simply put, he intellectually desires and emotionally longs for intimacy, but whenever he gets close to this desired goal, up go his defenses – walls of fear related to childhood abandonment and abuse. As such, Jeremy consistently (albeit unconsciously) engages in patterns of relationship sabotage whenever anyone gets close enough for him to feel emotionally threatened.

At the other end of the spectrum, whenever Jeremy is feeling lonely, longing, and even hopeless about his healthy (yet unmet) emotional needs, he can be found drinking and/or “numbing out” with compulsive porn use. When questioned, Jeremy casually says, “I come by these behaviors naturally, as my dad was an alcoholic and a womanizer.” His mother, he says, was “alternately loving – almost smothering – and then neglectful or verbally abusive.” When Jeremy was fourteen, his mother was diagnosed as bipolar and placed on medication. He says the meds caused her erratic behavior to lessen but not to disappear. And during childhood no one ever talked to him about what was wrong with his mom (or his dad). He was therefore left to reach his own self-blaming conclusions about the emotional confusion surrounding him.

So where to start in working with Jeremy? Is he alcoholic? Is he a sex addict? Does he have an attachment deficit disorder? Is he relationship avoidant? And noting that there are primary trauma issues that underlie his self-destructive behaviors, which are key and which are of lesser importance? Complicating matters is Jeremy’s desire to only examine his adult romantic relationships, and his statement that he doesn’t want to spend endless therapy sessions discussing his childhood, which he thinks was just fine, thank you very much. He also swears that he’s not an alcoholic, and he therefore has no interest in discussing his alcohol consumption. (The thought that he may also be sexually compulsive seems to have not yet occurred to him.)

Complex Approaches to Complex Problems

Jeremy presents a convoluted but hardly uncommon scenario – the “neurotic” yet functional client who brings with him (or her) multi-layered, interwoven patterns of childhood experience and adult acting out behaviors with negative consequences. Is he an alcoholic? Probably, though further investigation is needed. Is he a sex addict? Possibly, though, again, further investigation is needed. Does he have an attachment deficit disorder? Almost certainly, and it will have to be dealt with if he is ever to achieve his stated goal of developing and maintaining a healthy romance.

If it does turn out that Jeremy is chemically and/or sexually addicted, those issues will need to be addressed as quickly as possible, because little else can happen on the therapeutic front until behavioral problems like substance abuse and sexual compulsivity are in remission. And here is the reason: If we assume (as most clinicians do) that acting out with various addictions is a maladaptive attempt to self-soothe and self-medicate emotional discomfort, and that the basis of most psychodynamic psychotherapy is recognizing, experiencing, and processing or working through emotional discomfort (both past and present), then logic (and research) dictates that clients can’t grow past their emotional challenges while they are simultaneously self-medicating away the resulting anxiety, lability, and depression. In other words, as long as an addict continues to numb out with alcohol and/or sex (or whatever), that individual will struggle to make progress elsewhere in treatment.

In addition to getting Jeremy’s escapist, maladaptive coping behaviors under control, it seems clear that Jeremy will also need to address the one thing he most dreads talking about – his childhood trauma. And he will likely argue that his childhood was not in any way, shape, or form traumatic, since there were no fires or car wrecks or natural disasters, neither his school nor his neighborhood were violent, he was not bullied, he was not sexually abused, his father did not beat him, and his mother loved him as best she could despite her illness. Nevertheless, it is abundantly clear (based on, if nothing else, the reactive attachment style he is demonstrating in adult life) that Jeremy’s childhood was indeed traumatic, and that his early-life trauma most likely drives many if not all of his problematic adult behaviors. So for Jeremy to achieve any type of lasting emotional health, and certainly if he is ever to form a healthy long-term partnership, he will need to stop avoiding and start processing the past.

Complex Trauma

Traumatized individuals like Jeremy are often in denial about the trauma they’ve experienced. This is perfectly natural, as the obvious and understandable reaction to trauma is a desire to not relive it (resulting in denial, avoidance, numbing, and similar self-destructive activities). Because of this, many traumatized people who have issues later in life think that they are simply “crazy” or unbalanced, not recognizing their problematic behaviors as a natural response to early trauma. Often they are highly self-critical of themselves as a result. Essentially, they fail to take into account the serious impact of their traumatic experiences, and they therefore don’t allow for their all-too-human responses.

Complicating matters is the fact that most people typically think of trauma as related to singular incidents like car wrecks, rapes, robberies, and the like – something perpetrated by an outsider such as another driver, a sexual predator, or a violent criminal. And while events like these are most certainly a part of the trauma spectrum, they are only a small part. Perhaps far more common (and frequently unacknowledged) is the issue of attachment trauma, especially that which is chronic, occurring repeatedly over time. Much chronic attachment trauma is perpetrated by childhood caregivers – parents, relatives, teachers, and the like – though attachment trauma can also occur later in life. A few common forms of chronic attachment trauma are childhood sexual abuse, physical abuse, emotional neglect, emotional abuse, and bullying, along with adult domestic violence, sexual violence, emotional abuse, etc. Chronic trauma can also be cultural in nature, such as the ongoing difficulties sometimes caused by one’s race, gender, sexual orientation, religion, or physical limitations. Stress, serious illness, grief and loss, poverty, survivor’s guilt, war, natural disasters, and many other issues/events can also create chronic, long-term trauma.

An important thing to remember when assessing a patient’s trauma experience is that trauma is subjective. In other words, trauma is colored by the ways in which a particular person experiences a specific event or events, along with that individual’s innate capacity (genetic and learned) to tolerate and make sense of that experience. Thus, the alcoholism of Jeremy’s father may or may not have been seriously traumatic for him. The relative depth of pain caused by that particular issue will likely come out only as therapy progresses. The same can be said for his mother’s mental illness, though her inconsistent parenting style – smothering, then neglectful, then verbally abusive, then smothering again – was without doubt severely traumatizing. In fact, it appears to have influenced, rather strongly, Jeremy’s current highly disorganized attachment style. And then there was his father’s womanizing, which likely affects Jeremy’s adult perception of women, relationships, and love. Etc.

It is also useful here to incorporate the concept of “complex trauma.” Complex trauma can (and usually does) involve multiple forms of trauma (physical and/or emotional) that occur over time. Usually at least some of this trauma is chronic (repetitive). In other words, complex trauma involves layers of traumatic experience, and reactivity to each layer can manifest negatively later in life, usually in ways that mirror the initial trauma. In all likelihood this is what we are seeing with Jeremy. He gets into a relationship with a woman, she begins to get too close (to demand too much emotional vulnerability from him), he starts to feel uncomfortable (smothered), and then he begins to subconsciously act in ways that are likely to cause a breakup. The breakup occurs, he feels neglected and/or abandoned and perhaps he gets verbally abused, and then he regrets his unseemly behavior and another failed relationship. Feeling badly about himself, he self-medicates even more heavily than usual with alcohol and pornography. Then he feels badly about that so he vows to find a new relationship and to “make it work” this time. With this, the cycle begins anew. Essentially, in an attempt to avoid re-experiencing the trauma of his childhood, Jeremy is reliving it – re-victimizing himself by creating and then forcing the painful end of his many romantic relationships.

Multidimensional Issues Require Multidimensional Solutions

The treatment of complex trauma, along with the all-too-common co-occurring disorders (addiction, domestic violence, and the like) that tend to pair with it, is no easy task. The first step is recognizing the ways in which complex trauma may be manifesting in the individual facing you – most notably as depression, post-traumatic stress disorder (PTSD), dissociative disorders, self-harm disorders, and/or addiction. A client with one or more these diagnoses probably has a high degree of trauma waiting to be explored and de-escalated. There are numerous methodologies for addressing and de-escalating complex trauma in a therapeutic setting, and I hope to discuss at least a few of these in future blogs. For now, if you are interested in learning more about treatment of complex trauma, I suggest reading: Treatment of Complex Trauma: A Sequenced, Relationship-Based Approach by Christine Courtois and Julian Ford; Coping with Trauma: Hope through Understanding by Jon Allen; and Principles of Trauma Therapy: A Guide to Symptoms, Evaluation, and Treatment by John Briere and Catherine Scott.