YSTEMIC TRAUMATIC STRESS: THE COUPLE ADAPTATION TO TRAUMATIC STRESS MODEL

Briana S. Nelson Goff Kansas State University

Douglas B. Smith Kansas State University

Research traditionally has focused on the development of symptoms in those who experienced trauma directly but overlooked the impact of trauma on the families of victims. In recent years, researchers and clinicians have begun to examine how individual exposure to traumatic stress affects the spouses/partners, children, and professional helpers of trauma survivors. However, empirically supported, theory-based literature that identifies the mechanisms by which interpersonal or “secondary trauma” occurs in response to traumatic events is limited. Here, we present the Couple Adaptation to Traumatic Stress Model, a systemic model of the development of interpersonal symptoms in the couple dyad based on empirical literature. Potential mechanisms and clinical vignettes are included to describe the systemic processes that occur with trauma couples. Areas for future research and clinical implications also are identified.

Traumatic events have received much clinical and empirical focus in the last 25 years. Although traumatic experiences have been survived by people for centuries, scientific knowledge of trauma has increased in recent history. Much of the literature on trauma and posttraumatic stress focuses on the individual effects of trauma on the primary victim-the person who directly experienced the traumatic event (Herman, 1997; van der Kolk, McFarlane, & Weisaeth, 1996). In the past, the fields of traumatic stress and marriage and family therapy (MFT) have only occasionally intersected in the development and conceptual- ization of psychological trauma. As mental health professionals in the 21st century, it is necessary for MFTs to become knowledgeable in the field of traumatic stress.

THEORETICAL AND EMPIRICAL FOUNDATIONS OF SYSTEMIC TRAUMATIC STRESS IN COUPLES

This article highlights the importance of identifying a more systemic focus on traumatic stress within the MFT profession. The predominant focus in the trauma literature has been on the treatment of posttraumatic stress disorder (PTSD; American Psychiatric Association [APA], 2000), a disorder that, by definition, focuses on the intrapersonal effects of traumatic events on the individual trauma survivor. The literature that describes a systemic approach to trauma primarily involves secondary traumatic stress theory (Figley, 1983, 1998), adult attachment theory (Johnson, 2002), and the relational approach to trauma treatment (Sheinberg & Fraenkel, 2001).

Several terms have been used to describe these secondary effects, like “compassion fatigue” (Figley, 1995, 2002), “vicarious traumatization” (McCann & Pearlman, 990; Pearlman & Saakvitne, 1995),

Briana S. Nelson Goff, PhD, and Douglas B. Smith, MS, Marriage and Family Therapy Program, School of Family Studies and Human Services, Kansas State University.

Portions of this article were presented at the 2001 and 2002 AAMFT Annual Conferences. Address correspondence to Briana S. Nelson Goff, PhD, Marriage and Family Therapy Program, School of

Family Studies and Human Services, Kansas State University, 322 Justin Hall, Manhattan, Kansas, 66506-1403; E-mail: bnelson@ksu.edu

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“burnout” (Figley, 1998), “trauma transmission” (Baranowsky, Young, Johnson-Douglas, Williams-Keeler, & McCarrey, 1998), and “witnessing” (Weingarten, 2003, 2004).

Secondary Traumatic Stress The integration of MFT and traumatology has occurred predominately over the last decade.

Specifically, the work by Figley (1983, 1989, 1995, 1998, 2002; Figley & McCubbin, 1983) has bridged these, often distinct, fields. The theory of secondary traumatic stress contends that being in close contact with and emotionally connected to a traumatized person becomes a chronic stressor, and family members often experience symptoms of traumatization (Arzi, Solomon, & Dekel, 2000; Figley, 1983, 1995; McCann & Pearlman, 1990; Solomon, Waysman, Levy, Fried, Mikulincer, Benbenishty, Florian, & Bleich, 1992).

The basic premise behind secondary trauma theory is that individual stress symptoms are communicable, and those who are close to the trauma survivor can be “infected” with the trauma symptoms (Catherall, 1992a; Figley, 1995). Often the problems experienced by people close to a trauma survivor “mimic” (Coughlan & Parkin, 1987) the trauma symptoms in the survivor. This may result from an internal- ization process, whereby family members identify so closely with the experiences of the victim that they begin to internalize the trauma symptoms of the victim and experience their own stress reactions (Maloney, 1988). These effects are considered “secondary,” because they occur in those who have not been directly traumatized by the event. Frequently, these effects may resemble PTSD symptoms (Bramsen, van der Ploeg, & Twisk, 2002; Nelson & Wright, 1996), but may be less intense (Maltas & Shay, 1995).

Several authors have described the secondary effects traumatic events have on children (Barnes, 1998; Steinberg, 1998), spouses and partners (Arzi et al., 2000; Bramsen et al., 2002; Lev-Wiesel & Amir, 2001; McCann & Pearlman, 1990; Nelson & Wampler, 2000; Nelson, Wangsgaard, Yorgason, Higgins Kessler, & Carter-Vassol, 2002; Nelson & Wright, 1996), therapists (Figley, 2002; McCann & Pearlman, 1990; Pearlman & Saakvitne, 1995), emergency and medical professionals (McCammon & Allison, 1995), direct and indirect witnesses (Weingarten, 2003, 2004), and others who work and interact with trauma victims/ survivors on a personal level. The dilemma with the secondary traumatization hypothesis is that there is limited empirical support for the theory. Much of the literature on secondary traumatization gives brief mention of this concept, citing clinical support (Figley, 1983, 1989; McCann & Pearlman, 1990; Miller & Sutherland, 1999; Nelson & Wright, 1996).

The current empirical literature on trauma in couples that is available will be described next. For the purpose of this article, which specifically focuses on the couple relationship, “couple dyad” is defined as including two individuals in a committed partnership.

Empirical Studies of Secondary Traumatic Stress in Couples The research by Solomon and colleagues (Arzi et al., 2000; Mikulincer, Florian, & Solomon,

1995; Solomon, 1988; Solomon, Waysman, Avitzur, & Enoch, 1991; Solomon, Waysman, Belkin, Levy, Mikulincer, & Enoch, 1992; Solomon, Waysman, Levy, et al., 1992) has focused on the effects of combat trauma on the spouses/partners of veterans. Solomon, Waysman, Levy, et al. (1992) studied 205 wives of Israeli combat veterans to determine if combat stress reaction (CSR; a more immediate reaction to combat trauma) and PTSD in veteran husbands were related to psychiatric symptoms in wives. The authors found CSR and PTSD in husbands to be related to greater somatization, depression, anxiety, loneliness, hostility, and impaired marital, family, and social relations in the wives.

Mikulincer et al. (1995) found marital intimacy to be negatively related to levels of emotional distress among wives of combat veterans diagnosed with CSR and suggested that marital intimacy may moderate the relationship between symptoms of primary trauma and the development of secondary traumatic stress. In addition, they found that wives of veterans with CSR had greater psychiatric symptoms than the wives of veterans without CSR. Solomon, Waysman, Belkin, et al. (1992) reported greater conflict and reduced marital satisfaction and cohesion in couples where the husband had been diagnosed with CSR.

Riggs, Byrne, Weathers, and Litz (1998) examined the quality of the intimate relationships of male Vietnam veterans and their partners in the United States, comparing veterans with PTSD to a sample of veterans without PTSD. The results indicated that more than 70% of the PTSD veterans and their partners reported clinically significant levels of relationship distress, as compared with only 30% of the non-PTSD

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couples. The PTSD-positive couples reported significantly more relationship distress, difficulties with intimacy, and relationship problems than the PTSD-negative couples.

Lev-Wiesel and Amir (2001) examined secondary trauma in a nonclinical sample of spouses of Holocaust survivors. Approximately one-third of the partners reported secondary traumatic stress symptoms. The authors found that levels of anger and hostility, paranoia, and interpersonal sensitivity in Holocaust survivors were related to increased levels of secondary trauma symptoms in their spouses and decreased marital quality in the relationship. Related to the quality of the marital relationship, when child survivors of the Holocaust suffering from full or partial PTSD shared their memories of trauma with their spouse, the spouse reported lower perceived marital quality; however, when survivors reported no symptoms of PTSD, sharing traumatic memories had no effect on marital quality.

In a study conducted by Nelson and Wampler (2000), 96 clinic couples that reported a history of physical and/or sexual childhood abuse in one or both partners were compared with 65 clinic couples in which neither partner reported childhood physical or sexual abuse. The results indicated that the couples with an abuse history reported lower marital satisfaction and higher individual stress symptoms for both partners than those couples in which neither partner reported an abuse history. In couples in which only one partner reported an abuse history, there was no difference between the levels of individual stress symptoms for the abuse and no-abuse partners, indicating support for secondary traumatic stress theory.

Finally, research conducted by Nelson (1999) addressed the impact of traumatic experiences on dyadic relationships by comparing individual symptoms and relationship impairment measures between three clinical groups: Veteran couples, childhood sexual abuse survivor couples, and a control group of couples. The results from this study indicated that veterans experienced both higher individual stress symptoms and trauma symptoms than either the sexual abuse survivors or the clinical control primary partners. Childhood sexual abuse survivors reported more individual trauma symptoms than the clinical control primary partners but not significantly more stress symptoms. The partners in the veteran sample reported higher individual stress and secondary trauma symptoms than the partners in the other two groups, but there was no difference between the groups on trauma symptoms and no difference between the childhood sexual abuse survivor secondary partners and the clinical control secondary partners. In addition, there was not a significant difference in relationship impairment between the groups, indicating mixed support for the theory of secondary trauma, particularly the negative effects of trauma on the couple relationship.

Although some of the literature reviewed here indicates support for secondary trauma effects in couples, the results are varied. Studies have not identified the specific effects or mechanisms of trauma on interpersonal functioning. Separating marital problems from trauma symptoms is difficult, and the available research does not provide a clear description of the relationship between marital problems and individual symptoms due to trauma exposure.

Clinical Models of Systemic Traumatic Stress Emotionally focused therapy and attachment theory. One systemic theoretical and clinical approach

to trauma is the work by Johnson (2002). The application of emotionally focused couple therapy (EFT) to the treatment of trauma is based on Bowlby’s (1969) attachment theory and focuses on restructuring bonds between partners as a necessary part of trauma recovery. Although this couple therapy approach is not intended to replace individually oriented treatment modalities, especially for severe individual trauma symptoms (e.g., PTSD), Johnson emphasized that many traumatic experiences occur within a relational context and the consequences often are transmitted across or “contaminate” other interpersonal relationships. As Johnson (2002) stated, “if a person’s connection with significant others is not part of the coping and healing process, then, inevitably, it becomes part of the problem and even a source of retrauma- tization” (p. 7).

Johnson’s (2002) clinical approach emphasized establishing safety and stabilization, healing and restructuring the attachment bonds between partners, and reducing the marital distress and chronic pursue- withdraw patterns that trigger or maintain the trauma symptoms. Isolation, reduced emotional expression, and impaired interpersonal connections often result from trauma. Emotionally focused couple therapy with trauma survivors involves recognizing the systemic effects of trauma on both partners and creating the potential for the interpersonal relationship to provide a crucible (i.e., secure base) for healing from

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trauma. (For additional clinical applications of attachment theory, see Cassidy & Shaver, 1999.) Although EFT has received much empirical research on its effectiveness as a clinical method of treatment, the role of attachment security in the couple relationship of trauma survivors requires empirical support. Attachment will be described later as a possible mechanism of the systemic process that occurs in the trauma couple dyad.

Relational approach to trauma. Sheinberg and Fraenkel (2001) provided a description of a family- based approach to treating incest. Also using attachment theory, their clinical model “is designed to strengthen the safe, protective relationships between the child and her family members and to re-empower these individuals and relationships so that the family can be a safe, nurturing place” (Sheinberg & Fraenkel, 2001, p. 7). Although their approach primarily addresses the treatment of children’s trauma within a family context (relational trauma), it offers another description of an attachment-based, systemic perspective on traumatic stress. The authors also provide a description of the empirical support for relational trauma theory. However, a limitation of this model is that it may not generalize to other types of traumatic experiences (e.g., nonsexual, extrafamilial trauma).

The literature identified here provides a systemic focus and an initial description of the effects traumatic events have within a traumatized person’s system. There is clinical and anecdotal evidence of the systemic impact of trauma on couple and family systems of trauma survivors (Balcom, 1996; Catherall, 1992a; Figley 1989, 1998; Johnson, 2002; Nelson et al., 2002; Nelson & Wright, 1996; Sheinberg & Fraenkel, 2001). However, a clear and consistent description of the systemic or interpersonal effects of traumatic stress is needed, particularly a theoretical description of the unique systemic mechanisms specific to trauma.

Based on the reviewed literature, we will describe a systemic model of traumatic stress. Because of our clinical and empirical experience, and because the available empirical literature has focused primarily on the couple dyad, the couple subsystem is emphasized in the proposed model. In addition, although the specific individual and interpersonal symptoms may be unique to different types of traumatic experiences (e.g., sexual dysfunction may result from a history of childhood sexual abuse), wve purport that the systemic processes and mechanisms that occur may be similar across various traumas; thus, the proposed model may be applied equally to various traumatic events. We recognize the limitation that focusing exclusively on the couple subsystem presents but believe it is important to provide an initial description of a model of systemic trauma to eventually be expanded to other subsystems (e.g., parent-child, sibling) and systems (e.g., family of origin, communities) and across diverse types of traumatic events.

TRAUMATIC STRESS IN COUPLES: THE COUPLE ADAPTATION TO TRAUMATIC STRESS MODEL

The Couple Adaptation to Traumatic Stress (CATS) Model (see Figure 1) includes the primary and secondary trauma effects in the individuals, as well as the interpersonal effects within the couple system. Based on the literature, there are several empirical studies that support the CATS model. Each component of the model will be described next, including clinical vignettes that illustrate the model components.

Individual Level of Functioning: Symptoms of the Primary Trauma Survivor The individual trauma survivor may experience problems while the event is occurring (peritraumatic

effects) and may continue to be impaired after the event (posttraumatic effects). McCann, Sakheim, and Abrahamson (1988) categorized these individual effects as emotional, behavioral, cognitive, and biological symptoms. The symptom categories of PTSD (APA, 2000) are classified as reexperiencing (e.g., flashbacks, intrusive memories), arousal (e.g., anger outbursts, hypervigilance), and avoidance (e.g., avoiding reminders of the event, restricted range of affect). In general, these individual symptom categories comprise the level of functioning of the individual and can range from acute to chronic. When individual symptoms are cumulative and severe, they may result in PTSD or other disorders.

The potential range of trauma symptoms or level of functioning in the individual, which may include emotional, behavioral, cognitive, or biological symptoms, is depicted in Figure 1 in the left box.

In clients with a history of trauma, these individual problems may present as symptoms of depression