Complex trauma (C-PTSD) describes exposure to multiple traumatic events and the long-term impact of this exposure. It is therefore not surprising that children who were the target of family scapegoating abuse (FSA) are often suffering from undiagnosed and untreated complex trauma today…
Complex Trauma and the Scapegoated Child
Complex trauma (which is sometimes interchanged with terms such as C-PTSD, complex relational trauma, developmental trauma, and interpersonal trauma) is a relatively recent concept.
Whereas simple trauma refers to one single event which is obvious and definable, such as an accident or bodily assault, complex trauma describes exposure to multiple traumatic events and the long-term impact of this exposure. It is therefore not surprising that children who were chronically scapegoated by their parents or other significant family members may be suffering from undiagnosed and untreated complex trauma as adults.
More specifically: Repeated incidents of scapegoating abuse behaviors can leave the targeted child / adult survivor with signs of mental and emotional distress that overlap symptoms of complex trauma. These include (but are not limited to) the scapegoated individual experiencing a sense of social isolation and feeling mistrustful of others with a strong need to control their environment.
Because family scapegoating abuse doesn’t magically stop when the child matures into an adult, the scapegoating will most likely continue, resulting in the adult child being ‘triggered’ and re-traumatized from repeated exposures to abusive family members and their harmful “blaming and shaming”, rejecting behaviors. [To learn more about the overlap between family scapegoating abuse signs and C-PTSD symptoms, read my article What Family Scapegoating Abuse Survivors Need to Know About C-PTSD.]
Lily: A Client Case Study
Here’s an example of how family scapegoating abuse signs may sometimes overlap with C-PTSD symptoms: Lily presented in my practice saying she felt “anxious, lonely, hopeless, and lost”. She experienced deep fears of being rejected and avoided dating as a result. She had difficulty trusting others and struggled to set boundaries, which she felt was negatively impacting her relationships with others, including with her team at work.
Lily was especially worried because she was feeling increasingly distant from others and “numb and disconnected”. Lily also shared she often had “bad dreams” in which she was taken hostage and/or was suddenly being shot at with no means of escaping or getting help. She also experienced occasional panic attacks when visiting her parents and avoided seeing them as a result, and she felt guilt, embarrassment, and shame around this apparent loss of physiological and emotional control.
During our intake session, I learned that Lily grew up with the knowledge that her father had been disappointed with her because she wasn’t born a boy. When he verbally attacked her as a child by calling her “stupid”, “ugly”, and “fat” (such incidents were frequent), she figured it was because he was upset she “wasn’t a boy but some part of me knew I didn’t deserve it, even when I was very young.” Her father also drank too much at times and would become hostile and irrational, screaming at both her and her mother for various imagined offenses until he passed out.
Because she was the only child, Lily felt the weight of her father’s disappointment more acutely as she got older. Her father’s active psychoemotional and verbal abuse toward her gradually turned into disinterest and neglect by the time she entered adolescence. She did feel somewhat supported and loved by her mother, but couldn’t help but believe that her mother must be disappointed in her as well, given she couldn’t have any more children and her father had so desperately wanted a son to “carry on the family name.”
Psychoeducation and Assessing for Overlapping Symptoms
After reviewing Lily’s presenting issues and symptoms during the intake process, I explained to her that her father’s “blaming and shaming” behaviors (including his calling her things like “stupid”, “ugly”, and “fat”), and even his disinterest in her as she got older, constituted mental, emotional, and verbal abuse – something that surprised her but also gave her a sense of relief. “I thought there was something wrong with me that I just couldn’t get over my childhood – I never realized that what I went through was actually abusive. I thought abuse was mostly physical. Somehow having a name for what happened to me makes me feel better.”
Later, I Iet Lily know that it might be wise to assess her for symptoms of complex trauma (C-PTSD) in relation to her having been mentally and emotionally abused as a child. Lily expressed surprise, replying that she thought “PTSD was only for people who fought in wars and things like that.”
Lily’s response was understandable and also typical of clients that have never heard of C-PTSD and are not aware of how it might apply to them. I explained to Lily that complex PTSD differs from PTSD in that it acknowledges repeated and prolonged traumatic events experienced in childhood from which there is no escape, which is often applicable to the scapegoated child’s experience of their dysfunctional, rejecting, actively abusive family environment.
In Lily’s case, learning that what she experienced in childhood constituted abuse and having her symptoms of complex trauma identified and assessed allowed her to view herself and her mental health challenges with compassion. At the same time, understanding that she was an adult survivor of child abuse and had symptoms of C-PTSD instilled her with a sense of hope that recovery was possible. This in turn allowed her to commit to an efficacious trauma-informed treatment pathway designed to address both family scapegoating abuse (past and present) and her symptoms of complex trauma.
The Importance of Recognizing Complex Trauma
While C-PTSD is not yet formally recognized as a diagnosis in many countries, including the United States, the World Health Organization (WHO) will be including C-PTSD as a distinct, billable and insurable diagnosis internationally in the next ICD (11), effective January, 2022.
WHO’s decision to acknowledge C-PTSD as a distinct diagnosis is significant because clinicians practicing in the United States may now point to the WHO’s recognition of C-PTSD as a legitimate diagnosis reflecting “loss of emotional, psychological, and social resources under conditions of prolonged adversity” (Cloitre, Garvert, Brewin, Bryant & Maercker, 2013), which is typical of what those abused by family in childhood experience.
This is especially important due to the fact that when trauma symptoms go unacknowledged, treatment of the client and their symptoms is much less likely to be effective (regrettably, C-PTSD is not currently recognized in the Diagnostic Statistical Manual of Mental Disorders in the United States as a diagnosis, although the United States Department of Veterans Affairs does acknowledge C-PTSD as a distinct but sibling condition to PTSD).
Because C-PTSD is closely related to PTSD, complex trauma may be acknowledged via the use of specific PTSD coding offered in the current DSM (5) under Trauma and Stressor-Related Disorders, as this category addresses trauma caused by repeated and prolonged (over months and even years) stressors. However, it is my opinion that this category still falls short on acknowledging the particular constellation of symptoms associated with childhood abuse that are reflected in the diagnosis of complex PTSD.
The International Trauma Questionnaire (ITQ) as Assessment Tool
Numerous studies are currently taking place around the world as part of the standardization process of the International Trauma Questionnaire (ITQ) used to assess for core features of both C-PTSD and PTSD. The ITQ has been used, or is currently in use, in 29 countries across six continents. Preliminary evidence suggests that the ITQ is an instrument that produces reliable and valid scores and can adequately distinguish between PTSD and C-PTSD cross-culturally.
Interestingly, in the United States, studies using the ITQ indicated that women were more than twice as likely to meet criteria for PTSD and for C-PTSD than were men. Given that the most frequently endorsed DSO (disturbance of self organization) cluster was negative self-concept, the critical role problems in negative self-concept may play in C-PTSD would seem to warrant special attention for clinicians working with clients who report being chronically scapegoated, blamed, shamed, neglected, and/or rejected by a parent or other significant primary caregiver or family member. Learn more about the ITQ, below:
“The International Trauma Questionnaire (ITQ) is a brief, simply-worded measure, focusing only on the core features of PTSD and CPTSD, and employs straightforward diagnostic rules. The ITQ was developed to be consistent with the organizing principles of the ICD-11, as set forth by the World Health Organization, which are to maximize clinical utility and ensure international applicability through a focus on the core symptoms of a given disorder.”
Cloitre M., Garvert D. W., Brewin C. R., Bryant R. A., & Maercker A. (2013). Evidence for proposed ICD-11 PTSD and complex PTSD: A latent profile analysis. European Journal of Psychotraumatology, 4, 2070
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