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Growing empirical evidence suggests that the most severe traumatic stress symptoms develop in individuals with accumulated interpersonal trauma histories (Cloitre et al., 2020; Karatzias et al., 2018a; 2018b; Knefel et al., 2019). Polytraumatization that is interpersonal in nature has many detrimental impacts on individual well-being, including increases in functional impairment, retraumatization, and early mortality (Hyland et al., 2017; Karatzias, et al., 2017). In the recently updated International Classification of Diseases 11th Edition (ICD-11), a distinction has been made between posttraumatic stress disorder (PTSD) and its sister disorder, complex-PTSD (Karatzias, et al., 2017; ICD-11, 2021). Research shows that chronically trauma-exposed individuals may be more likely to develop C-PTSD than PTSD, which is due to the higher prevalence of interpersonal trauma that is experienced globally compared to more isolated or impersonal traumatic events (Cloitre et al., 2020). A key clinical and policy consideration at this time is expanding access to evidence-based interventions (EBIs) that can address the underlying interpersonal disturbances experienced by C-PTSD populations.
Such interpersonal traumatic experiences for those with C-PTSD can include adverse childhood experiences (ACEs), childhood sexual abuse, intimate partner violence, systemic racism and refugee status (Hyland et al., 2017). The underlying feature of the types of trauma that tend to lead to C-PTSD as opposed to PTSD often involve repeated neglect or violations from caregivers, loved ones or one’s community that is otherwise established to keep one safe. In this sense, relationships are central to both the development of C-PTSD and also the ongoing sense of threat and difficulty this population experiences with close others. The breakdown of one’s ability to experience safety in relationships has a deteriorative impact on individuals with grave consequences, including a significantly heightened risk of early mortality, comorbidity and retraumatization compared to other diagnoses including PTSD (Cloitre et al., 2020; Hyland et al., 2017; Karatzias et al., 2018; 2019; Mahoney et al., 2019; Matheson, & Weightman, 2020). C-PTSD impacts tens of millions globally, both directly and indirectly, and is thus an important public health concern that can be addressed with improved prevention and treatment efforts.
In addition to prevention efforts that might address reducing ACEs or intimate partner violence, a critical concern in addressing C-PTSD is the expansion of up-to-date assessment and EBIs in clinical settings. Current policies and procedures regarding clinical care for traumatic stress tend to rely on EBIs for PTSD (Karatzias et al., 2018; 2019). However, research indicates that such interventions may fall short in treating C-PTSD-specific symptomology, also known as the disorganized sense of self (DSO) symptom cluster. The DSO includes acute difficulty in relationships, a pervasive negative sense of oneself, and difficulties in emotion regulation, in addition to the traditional PTSD symptoms of hypervigilance, re-experiencing and avoidance (Hyland et al., 2017). Traditional EBIs for PTSD—such as exposure or cognitive behavioral modalities—may not always have the capacity to address the deeply interpersonal core of C-PTSD. Combined results from multiple meta-analyses indicate that traditional individual therapies for PTSD may not be as effective for C-PTSD-specific symptoms (Mahoney et al., 2019). Researchers and clinicians alike have thus identified the unique utility of implementing relational interventions for C-PTSD populations, including group and family therapies (Pearlman et al., 2005; Roundy, 2017; Matheson, & Weightman, 2020).
A policy-based barrier to care for those with C-PTSD is the current standard in mental health care of treating disorders at the individual level. Although this is an essential paradigm for the treatment of many disorders, systemic (or relational) interventions—such as attachment-based family therapy, cognitive-behavioral conjoint therapy for PTSD, emotionally focused couples therapy and solution-focused brief strategic family therapy—may be needed. Indeed, research on systemic interventions has shown that integrating one’s family system into treatment can produce significant results in decreasing individual mental health symptomology (Blow et al., in press; Matheson, & Weightman, 2020; Wittenborn et al., 2019). In addition to addressing ongoing relational difficulties within the family system, systemic interventions offer unique benefits of integrating social support within therapy, psychoeducation for family members and sustained adjustments within a patient’s family network that reduce the burden of change from just the individual who is experiencing symptoms.
Despite the understood effectiveness of integrating relational support into C-PTSD intervention, policies supporting relational interventions for C-PTSD have not yet caught up with the research. This delay is also because the research in this area is still in development and policies tend to rely upon the more established and individualized standard of care (i.e., focus on an individual as opposed to the family system). Though this is shifting, efforts for future policy should focus on expanding the conceptualization of traumatic stress assessment and intervention from systemic perspective (AAMFT, 2021).
Current barriers to care in terms of delivering effective interventions for C-PTSD exists in three areas. First, in addition to the current consensus regarding the benefits and fit of relational interventions for C-PTSD populations, more research should focus on determining and adapting systemic EBIs for C-PTSD specifically. Next, governmental and organizational agencies can expand access to systemic care by including systemic therapists and systemic disorders in mental health care coverage. For example, several U.S. states do not include systemic therapists in their Medicare or insurance coverage; this policy alone may cut off access to care for millions of individuals. Finally, policy along with clinical care providers must move to integrate the updated conceptualization of traumatic stress so that individuals can receive diagnoses for either PTSD or C-PTSD, which can then inform which types of interventions may be most effective.

About the Author

Jennifer VanBoxel (she/her/hers) is a doctoral candidate in human development and family studies with a concentration in couple and family therapy at Michigan State University. Jennifer’s area of research focuses broadly on addressing therapeutic needs of interpersonal trauma populations in systemic family therapy. More specifically, she is interested in testing, integrating and adapting systemic and attachment-based interventions for complex posttraumatic stress disorder (C-PTSD) with couples, individuals and families.


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