Chapter One – Problems and SymptomsTreatment-Guide-Chapter-1

This chapter provides a brief overview of the social context and psychological outcomes often associated with complex trauma in adolescents.

It is important to stress at the outset that most traumatized youth will not experience all of the difficulties described below. Some, nevertheless, will encounter a significant number of these. More detailed discussions of the psychosocial contexts and effects of complex trauma relevant to adolescents and others can be found in Briere and Spinazzola (2009), Cook, et al. (2005), Courtois and Ford, (2009), and Ford and Courtois (2013).

Immediate issues

Although many of the effects of trauma exposure are chronic in nature, and may not require rapid intervention, others are more severe, and may endanger the client’s immediate wellbeing, if not his or her life. Some of these issues have to do with the adolescent’s environment; his or her victimization may be ongoing, as opposed to solely in the past, and his or her social context may continue to be invalidating, if not dangerous. Other issues may reflect the impact of trauma on the adolescent’s personality, internal experience, and relationships with others: he or she may be suicidal, involved in maladaptive substance use, or engaging in other forms of risky behavior.

Environmental risks

When complex trauma occurs within the context of socioeconomic deprivation or social marginalization, it is unlikely that conditions will have substantially changed at the time of therapy. The adolescent who was abused in the context of caretaker neglect or nonsupport, or who was assaulted as a result of community violence or gang activity, and who lives with poverty, poor nutrition, inadequate schools, social discrimination, and/or hard-to-access medical and psychological resources, is often struggling not only with a trauma history and social deprivation, but also the likelihood of additional trauma in the future. The fact that negative economic and social conditions increase the risk of interpersonal victimization has direct implications for treatment: as will be discussed later in this guide, optimal assistance to multiply abused or traumatized adolescent often require not only effective therapy, but also advocacy and systems interventions (e.g., Saxe, Ellis, & Kaplow, 2007).

The traumatized adolescent’s environment may be noteworthy for not only social marginalization or deprivation, but also for the continued presence of those involved in his or her victimization (Briere, 1996). If the client was sexually or physically victimized by an adult or peer, there is often little reason to assume that the danger from such individuals has passed. Hate crimes such as assaults on minorities, the homeless, and gay, lesbian, or transgendered youth are unlikely to stop merely because law enforcement has been notified. As is true for adverse social conditions, the continued presence of perpetrators in the adolescent’s environment may require the clinician to do more than render treatment – ultimately, the primary concern is the client’s immediate safety.

Self-endangerment

In addition to dangers present in the social and physical environment, the adolescent may engage in behaviors that threaten his or her own safety. In most cases, such self-endangerment arises from the effects of trauma and neglect. Although the youth may appear to be “acting out,” “self-destructive,” “borderline,” or “conduct-disordered,” most behaviors in this regard appear to represent adaptations to, or effects of, prior victimization (Runtz & Briere, 1986; Singer, et al., 1995).

The primary self-endangering behaviors seen in adolescents suffering from complex trauma exposure include suicidal behavior, intentional (but nonsuicidal) self-injury, major substance use or abuse, eating disorders, dysfunctional sexual behavior, excessive risk-taking, and involvement in physical altercations (Briere & Spinazzola, 2009; Cook et al., 2005). Regarding the latter, the traumatized adolescent may not only seek out violent ways to externalize distress, but also may be further traumatized when others fight back, the aggression-retaliation cycle associated with gang activity occurs, and/or they become involved in the juvenile justice system. The adolescent also may experience less obviously endangering relational difficulties, such as poor sexual-romantic choices and inadequate self-protection – including passivity or dissociation – in the face of dangerous others.

Some of these difficulties may explain what is referred to in the literature as revictimization: those who were severely maltreated as children have an elevated risk of being assaulted later in life (Classen, Palesh, & Aggarwal, 2005). This phenomenon may result in a scenario well-known to clinicians who work in the area of complex trauma: the abused and/or neglected child may, as he or she matures, engage in various activities and defenses (e.g., substance abuse, dysfunctional sexual behavior, or aggression) as a way to reduce posttraumatic distress, only to have such coping strategies ultimately lead to even more victimization and, perhaps, even more self-endangering behavior (e.g., Koenig, Doll, O’Leary, & Pequegnat, 2003). In this regard, self-endangerment – as much as dangerous environments – requires the clinician to focus on safety as much as symptom remission.

Longer-term trauma outcomes

In addition to the acute issues outlined above, many adolescent trauma survivors suffer the chronic, ongoing effects of previous adverse experiences. Arising from maltreatment that may have begun in early childhood (e.g., early neglect or abuse) and have continued into adolescence (e.g., victimization by peers or adults), such impacts may emerge as relatively chronic psychological symptoms, potentially presenting as one or more psychiatric disorders.

In some cases, symptomatic or “acting out” behaviors may represent coping responses to trauma. These include tension reduction behaviors, such as self-injury, repetitive or otherwise problematic sexual behavior, bulimia, excessive risk-taking, compulsive stealing, and some instances of aggression (Briere, 1996, 2002). These activities may serve, in part, as a way for the adolescent to distract, soothe, avoid, or otherwise reduce ongoing or triggered trauma-related dysphoria, as noted later in this chapter.

Whether symptomatology, skill deficits, or coping strategies, there are a number of longer-term impacts of childhood and adolescent trauma. The most common and significant of these are:

  • Anxiety, depression, and/or anger
  • Cognitive distortions
  • Posttraumatic stress
  • Dissociation
  • Identity disturbance
  • Affect dysregulation
  • Interpersonal problems
  • Substance abuse
  • Self-mutilation
  • Bingeing and purging (bulimia)
  • Unsafe or dysfunctional sexual behavior
  • Somatization
  • Aggression
  • Suicidality
  • Personality disorder

The reader is referred to the following literature reviews for more information on these trauma-impact relationships (Briere & Spinazzola, 2009; Cole & Putnam, 1992; Cook, et al., 2005; Courtois & Ford, 2009; Ford & Courtois, 2013; Herman, Perry, & van der Kolk, 1989; Janoff-Bulman, 1992; Myers, et al., 2002; Putnam, 2003; van der Kolk, Roth, Pelcovitz, Sunday, & Spinazzola, 2005).

As noted earlier, these various symptoms and coping strategies are sometimes referred to as “Complex PTSD” (Herman, 1992), “Disorders of Extreme Stress Not Otherwise Specified” (DESNOS; van der Kolk, et al., 2005), or as evidence of a developmental trauma disorder (van der Kolk, 2005). The breadth and extent of these outcomes generally requires a therapeutic approach that involves multiple treatment modalities and interventions, as opposed to solely, for example, cognitive therapy or therapeutic exposure (Courtois & Ford, 2009). ITCT-A allows the clinician to address these various difficulties in a relatively structured way, which is, at the same time, customizable to the specific clinical presentation and needs of the truncated.