Couples Therapy with Traumatized Partners

Couples Therapy with Traumatized Partners

Traumatic events, especially events that occur in the context of close relationships wound us deeply, teaching us that not only is the world a dangerous place, but those who we rely on the most for comfort in such a world are the people who can wound us the most. Inevitably, when we come to embrace others and hold them close, these wounds are touched. The way we react to that touch often makes it hard for those we love to come close and give us the support we need to heal.

To heal from what Judith Herman (1992) calls, “violations of human connection” trauma that is inflicted by those we need and love, we need new, positive experiences of connection and caring. Often, a healing relationship with an individual therapist can help us, but the therapist is not there in the middle of the night when the ghosts of trauma come for us; we need our partner to help us fight those ghosts. Often, when partners do not understand how deeply wounded we are, and how everyday interactions contain echoes of past terrors, they brush against those wounds, confirming all the fears that the trauma left us with.

Present relationships can be a vital part of the healing environment for trauma survivors or they can be part of the problem, helping to maintain trauma symptoms and dysfunctional methods of coping. Couples therapy can make the difference between a new healing connection with others and on-going re-traumatization.

Why Couples Therapy?

The ability to derive comfort from another human being appears to be a more powerful predictor of whether trauma symptoms improve and self-destructive behavior can be regulated than the history of the trauma itself (van der Kolk, McFarlane & Weisaeth, 1996). Marital therapy as a modality is able to directly address key elements in the healing environment, such as the offering of comfort, the fostering of confiding and the confirmation of the self in everyday interactions as lovable and worthwhile.

Traditionally, however, the treatment of trauma has focused on individual and group therapy, rather than on couples interventions. However, there is a growing recognition that the multidimensional nature of post traumatic stress disorders often requires a combination of several different treatment approaches and modalities, and that couples therapy can be a potent addition to the treatment of trauma.

Why do trauma survivors and their spouses seek out marital therapy? The answer is in the nature of trauma itself. Trauma intensifies our need for close supportive relationships and at the same time undermines our ability to create and maintain such relationships. If we look at the after effects of trauma, defined in the DSM IV as an experience of intense fear, horror and helplessness, the potential impact of trauma on a couple’s ability to create a loving relationship becomes clear.

Occasionally couples come to therapy with circumscribed reactions to trauma, for example, even in the happiest of marriages, where there has been no previous trauma to undermine either partner’s faith in others, a traumatic event external to the relationship itself, such as the accidental death of a child, can undermine the couple’s relationship. In extreme circumstances, if partners cannot support each other and stand together, perhaps because of different styles of grieving, they tend to become polarized and alienated from each other. Relationship distress then interferes with constructive coping and negative coping strategies, such as withdrawal or blaming, exacerbate relationship distress.

In this kind of scenario, couples therapy may be the best intervention and may be sufficient, if the therapist can find ways to help the couple support and comfort each other. The therapist might help the couple construct what Charles Figley (1989) calls a healing theory, as to why the trauma occurred and why they each dealt with it the way they did, and help them to respond empathetically to each other.

Very often however, couples come to therapy because past traumas, such as childhood sexual or physical abuse, have undermined their ability to form a secure bond with each other and have to a great extent, defined their relationship. In these cases, the trauma survivor and also his/her partner are often suffering from post traumatic stress disorder and will usually be involved in some form of individual treatment in addition to couples therapy. In these couples, the classic aftereffects of traumatic experience as described in the DSM IV and how each of theses effects impact the couple’s relationship are evident.

The Effects of Trauma

The first effect of trauma mentioned in the DSM is persistent reexperiencing. This includes intrusive thoughts, nightmares, flashbacks and physiological reactions to trauma cues. These symptoms can be disruptive in themselves. For example, a victim of childhood abuse may react extremely negatively to her spouse coming up behind her and encircling her with his arms. For her, this cues a sense of helplessness that evokes an immediate fight, flight or freeze response.

These responses also often alienate the partner, who may not understand his wife’s reaction and then react negatively to her precisely when she needs him the most. Activities such as confiding or affectionate holding or lovemaking that have the potential, even in distressed couples, to soothe and comfort, become laden with trauma cues and dangerous in themselves for the survivor and also for the spouse, who is never able to reliably predict his or her partner’s response. The trauma survivors sense of shame often precludes even talking about such responses, so that the partner has little chance of understanding and loses any sense of positive control in the relationship.

As one client described it, “I’ve read the book, the one that explained what trauma was, but I still don’t know what is going to happen from minute to minute here. I feel like I’m going crazy trying to guess how she will react. And I never get any of my needs met.” Not knowing how to make a difference and experiencing his or her partner as unpredictable, this partner often then withdraws and, as the survivor experiences it, leaves him or her to face the ghosts of trauma alone. This abandonment then exacerbates the survivor’s insecurity in the relationship.

The second after effect of trauma described in the DSM IV is avoidance of trauma cues and the numbing of general responsiveness. Partners often describe survivors as detached or estranged and as seemingly indifferent or unengaged in everyday life and interactions. Emotional engagement, one of the prime predictors of marital satisfaction and stability (Gottman & Levenson, 1986) becomes almost impossible and isolation pervades the relationship. Isolation also then tends to maintain trauma symptoms and prime problematic attempts at self soothing, such as drinking or substance abuse.

Apart from avoiding any situation where vulnerability may arise, which already constricts interactions between partners, survivors’ general lack of emotional responsiveness is aversive to their partners. In fact, this is a common complaint made by non-traumatized distressed couples and a major reason for initiating couples therapy. In couples dealing with trauma this is particularly problematic. For example, research suggests that combat veterans wives find their partner’s withdrawal extremely aversive and these partners become profoundly lonely and vulnerable to a variety of somatic complaints.

If accessibility and responsiveness is taken as the basis of a secure bond, as outlined in the literature on attachment (Bowlby, 1988), this numbing and avoidance on the part of the survivor will, in all likelihood, evoke growing insecurity and distress for the other partner and create or exacerbate relationship distress.

Numbing and avoidance also makes new experiences, that might provide new information to the trauma victim, or a new experience of connection, hard to come by. There is little opportunity then to potentially balance or correct the negative lessons learned in the trauma experience about what it is to be vulnerable to or dependent on others. More globally, the loss of ability to regulate affective states is generally accepted as a, if not the, primary effect of trauma.

Survivors describe themselves as being in a perpetual state of alarm or numb. Neither of these states make for open flexible communication or interactions with others. Our emotions are key signals that communicate our needs and concerns to those close to us in a manner that pulls for specific responses; weeping disarms and evokes compassion and anger challenges or cues compliance. Trauma scrambles the main signaling system that organises our interactions; no wonder the partners of survivors often speak of feeling lost, bewildered and inadequate and survivors themselves can no longer identify or express their longings and needs.

In some cases victims are so absorbed in dealing with past events and so uninvolved in the present that partners experience them as “there” rather than “here” and the relationship as essentially lost. In the novel, The English Patient, there is a point where the nurse realizes that for her lover, even when she is actually making love with him, she is just on the “periphery”; his attention is focused on “what is dangerous”. Sometimes this kind of absence or dissociation is specific to particular situations; for example, a partner may ask why, after years of seemingly normal lovemaking, his spouse will not allow him to touch her. He is not comforted by his wife’s response that she was “never there” in their lovemaking and in fact felt that she had never really slept with anyone except her abuser.

The third aftereffect noted in the DSM IV is increased arousal, hypervigilance and irritability. This often shows up as outbursts of anger, hostility and an extreme intolerance to any difficulty or threat. It is important for the couples therapist to ask specifically about violence and abuse and if necessary, to refer violent partners for help with this issue, preferably before beginning couples therapy. The victim’s partner often comes to be defined as the enemy, as yet another betrayer, particularly since survivors have such compelling reasons not to trust and to be vigilant for slights or signs of threat. Such hypervigilance often occurs exactly when the victim is vulnerable and needs a safe haven and results in the partner feeling driven away and the victim again feeling alone and abandoned.

Impairment in social functioning is one of the diagnostic features of post traumatic stress disorder and it is not hard to understand why, given the problems described above. Impairment is also not only confined to the individual; the effect of trauma on the spouse and the family are profound. The clinical reality of post traumatic stress disorder also often involves depression and together with that depression a sense of self as shameful, unworthy of care and even responsible for and deserving of the trauma. In incest survivors the definition of the self as bad and responsible for the abuse may be viewed as way of preserving the much needed relationship with abusing attachment figures. These survivors, often find it almost impossible years later to believe that their partner could know them and still care for and respect them. The nature of shame is to “hide and divide” (Pierce, 1994) and for these people basic elements of intimacy, such as self-disclosure, can then be exceedingly problematic.

Couples Relationships can Help Recovery

The flip side to this picture, which suggests that for trauma survivors and their partners creating a close positive relationship can be a monumental challenge, is that the couple relationship, if fostered and supported, can have a potent impact on the recovery process, and that couples therapy has the potential to not only improve the couples relationship but also to contribute to this recovery. Any couples therapy that includes survivors will need to include special features, such as a psychoeducational component about the nature of trauma and a heightened awareness of the potential for violence and coping mechanisms such as substance abuse and self-injury.

Some interventions may also be more appropriate than others for these couples. Approaches to couples therapy that focus on dealing with affect and the systematic creation of a secure attachment bond, such as Emotionally Focused Couples Therapy (EFT, Johnson, 1996) may be particularly appropriate. Secure attachment is seen by many trauma experts as providing the primary defense against the effects of trauma (van der Kolk, McFarlane & Weisaeth, 1996).

How can couples therapy can make a difference?

  • The therapist can help the couple create a more secure bond. Such a bond provides a positive alternative to regulating negative affect associated with the trauma through destructive strategies, such as self-mutilation, numbing and dissociation or substance abuse. Turning to one’s partner for comfort not only regulates trauma responses but also increases the intimacy in the relationship. Hard times can bring partners together as well as distance them from each other.
  • Ongoing confiding in an empathic significant other promotes the continued processing, naming and understanding of the trauma. Confiding promotes the cognitive reorganization of traumatic experience and the partner’s response adds new information that helps in the creation of new meanings. For example, the partner may focus on the victims courage rather than his or her “weakness.”
  • As the relationship becomes a safe haven, numbing is less necessary and engagement in everyday existence increases; corrective emotional experiences can then occur that change the impact the trauma has on the victim’s life.
  • In the social support literature, the offering of emotional support, including the confirmation of worth, is considered the most crucial form of support. Trauma victims particularly need a relationship where the self is defined as benign and worthy of love and caring. A partner is usually the most potent source of such confirmation.
  • The partner is given the opportunity to express how the trauma, and the marital distress that is linked to the trauma, has impacted him/her and given support to deal with this impact. This partner is then able to become more accessible and responsive to the victim and is usually very relieved to discover a way to help his or her victimized partner heal.
  • Marital distress, which is, in itself, a significant stressor and is associated with depression, is reduced. The traumatic experience and the distressed interaction patterns in the relationship become the enemy, rather than the other spouse. Isolation, which tends to exacerbate fear and anxiety, is reduced and the ability to trust is fostered.

In general, safe attachment has been identified as the primary defense against trauma. Couples therapy is able to directly address the bonding process between partners. A client remarked, “I want her to find a safe place to rest from all this horror in my arms, instead of driving too fast in her car, all alone, on the freeway, like she does now.”

To work with these couples the therapist needs to stay with the victim and his or her partner and help them deal with intense negative affect, particularly fear, and express this affect in a manner that draws the other to them, rather than in a way that initiates stuck cycles of defense and distance. Dealing with strong affect, such as fear, which constricts how people process information and how they interact with others, is part of the everyday process of marital therapy. Helping these couples is then an intensification of a process with which most marital therapists are already familiar.

Couples therapists can have an enormous impact here, helping the couple redefine their relationship and their responses to trauma and alleviating the stress this places on the family as a whole. Many interventions, such as exposure or flooding can only address one set of trauma symptoms; couples therapy is able to address each of the symptom groups that constitute post traumatic stress disorder, re-experiencing, avoidance and numbing and hyperarousal. These symptoms are also alive and accessible for modification as they are played out, in front of the therapist, as part of the drama of an intimate relationship. The creation of a satisfying intimate relationship is perhaps one of the few things that can rob trauma of its sting and endow life with new meaning, even in a dangerous world.

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