Complex Relational Trauma
Darius, 34, Black veteran, currently unemployed
Fictional teaching case
Compare the formulations ↓Presentation
Nightmares most nights: combat scenes that blur into childhood memories. Hypervigilant in public: sits with his back to the wall, scans exits, flinches at sudden noise. Emotional numbness that he describes as 'a wall of nothing.' Two relationships ended in the past year: both partners said he was 'impossible to reach.' Drinks 4-5 beers nightly, more on weekends. Hasn't held a job for more than three months since discharge. Referred by the VA after a bar fight. Says: "I don't feel anything anymore. I'm just going through the motions. At least when I was over there, it made sense."
Read the full case history and clinical context
Two combat deployments to Afghanistan, ages 22-26. Childhood marked by physical abuse from father: belt, fists, once thrown into a wall at age 8. Witnessed his father beat his mother regularly. Mother was emotionally checked out: present in the house but unreachable. Older brother left home at 16 and cut contact. Darius enlisted at 18 to get out. Describes the military as 'the first place that made sense' until it didn't. Honorable discharge at 26. No sustained relationships or employment since. This is his third attempt at therapy: walked out of the previous two when asked about childhood.
Compare how approaches understand this case
Two approaches to begin with; change them below. These are starting examples, not a clinical ranking.
Choose up to three approaches:
Showing 2 of 11 formulations.
CPT
Stuck points: 'The world is dangerous,' 'I should have done more,' 'No one can be trusted.' These trauma-related cognitions maintain PTSD symptoms and block recovery.
Identify stuck points, Socratic questioning, ABC worksheets, challenging problematic beliefs about safety, trust, power, esteem, and intimacy.
"You wrote that you should have protected everyone. Let's look at that stuck point: what evidence do you have for and against that belief?"
DBT
Biosocial model: a biological vulnerability to intense emotion transacting across a lifetime with invalidating environments, first a house where his own experience was met with violence or with nothing, then a service culture with nowhere to put it. Trauma is part of that history rather than the origin of the dysregulation. Drinking is a solution that works. The numbness is inhibited grieving, the other pole of the same problem.
Stage 1, in hierarchy order: life-threatening behavior first, including the fight and anything suicidal or self-injurious; then therapy-interfering behavior, which is the live target given that he has walked out of two previous courses; then quality-of-life-interfering behavior, where the drinking sits. Diary cards. Skills group alongside individual therapy. Consultation team for the therapist.
"The drinking makes sense as a way to manage what feels unmanageable. But it's also keeping you stuck. Can we find some other ways to ride the wave?"
STAIR
Complex trauma has compromised emotion regulation and interpersonal capacities. These skills deficits must be addressed before trauma narrative processing can be effective.
Phase 1: Emotion regulation skills, interpersonal skills, psychoeducation on trauma. Phase 2: Modified prolonged exposure to trauma narratives.
"Let's practice naming what you're feeling with more precision, not just 'nothing,' but what's underneath the nothing."
IFS
Firefighter parts (drinking, numbness) are protecting exiled parts carrying combat and childhood pain. Managers (hypervigilance) keep the system on alert. Self is not damaged or gone, but the protectors are so fully blended that almost none of its energy reaches the surface.
Befriending protectors (the drinker, the numb one, the hypervigilant one), understanding their protective function, eventually accessing and unburdening exiles.
"The part of you that drinks: can you get curious about it? What is it afraid would happen if it stopped protecting you?"
Psychoanalysis
Repetition compulsion: the failed relationships reenact early attachment trauma. Numbness is a massive defense against overwhelming affect. Drinking further suppresses what threatens to emerge.
Establishing safety in the therapeutic relationship. Gradually exploring how combat trauma resonates with childhood experience. Interpreting defenses as they emerge in the transference.
"You said the numbness started over there. Then you mentioned your father, and you stopped. I would like to know what came to mind in that pause."
NARM
Connection and Attunement organize most of what Darius brings. The wall of nothing is a Connection adaptation: not an absence of feeling but a long withdrawal from his own body and from contact, formed in a house where being present was dangerous. Attunement runs underneath it, from a mother who was in the room and unreachable, leaving him without a reliable sense of what he needs or any expectation that naming it would produce anything. Trust is visible too, though in Heller's sense it concerns the danger of depending on someone rather than the world being dangerous, and in Darius it looks like a self-sufficiency that has cost him two partners. Combat did not create any of this. It confirmed it. The numbness is not a symptom to remove; it is the shape the adaptation took, and it worked. The drinking sits in the gap between the survival style and the contact he cannot let himself have.
Work at the intersection of identity, emotion, and soma in present time, not excavating trauma memories but tracking how the survival styles organize Darius's experience right now, in the room. When he goes numb, what is the body doing? When connection is offered, by the therapist or by a partner, what happens in the chest, the gut? The unmet developmental needs are not supplied by the therapist. NARM works the other direction: notice the adaptation as it operates, notice what it costs, and support whatever capacity for connection and agency is already there.
"You said you don't feel anything. And something brought you here. Both of those are true at the same time, and I would rather stay with that than resolve it. As we sit here, what happens in your body when I say the word wanting?"
Somatic Experiencing
Incomplete survival responses from both combat and childhood abuse. The nervous system oscillates between hyperactivation (hypervigilance) and hypoactivation (numbness). Alcohol is self-medication for dysregulation.
Titrated pendulation. Finding resource states. Slowly renegotiating traumatic activation. Completing fight responses that were truncated.
"Notice that tension in your shoulders. Your body is still bracing. What do your arms want to do right now?"
Adaptive Disclosure
Darius's combat experiences likely involve more than one wound type: life-threat (fear-conditioned PTSD), traumatic loss, and possibly moral injury from acts that violated what he believed. Standard protocols treat all combat trauma as fear-based. Nothing in the referral establishes which of the three is doing the most work here, and the numbness alongside 'at least when I was over there, it made sense' is exactly the presentation assessment has to sort out rather than assume.
Assessment of which wound types are present. Life-threat memories processed with exposure-based techniques. Traumatic loss addressed through imaginal conversation with fallen comrades. Moral injury addressed through dialogue with a compassionate moral authority.
"I'd like you to imagine someone you deeply respect: maybe a mentor, a chaplain, someone whose moral judgment you trust. Imagine telling them what happened. What do you think they would say to you?"
EMDR
Multiple memories stored dysfunctionally, from both combat and childhood, still holding the images, affect, body sensation, and negative self-belief they carried at the time. Under the adaptive information processing model it is these unintegrated memory networks, not present danger, that the symptoms are driven by.
Stabilization, identify target memories (worst combat memory, worst childhood memory), standard protocol reprocessing, future template.
"Bring up the image and the negative belief about yourself. Notice what you feel in your body. Now follow my fingers."
Lifespan Integration
Fragmented temporal integration: Darius's nervous system is stuck in past time, experiencing childhood and combat danger as present. The numbness and drinking are attempts to manage a body that doesn't know the danger has passed.
Build a timeline of memories from birth to present. Repeat the timeline multiple times per session, allowing the nervous system to integrate past as past. Standard LI protocol first, then Birth-to-Present for attachment repair.
"We're going to go through your life timeline again, just let the images come, one after another. You don't need to narrate or explain. Your body knows how to do this."
Narrative Exposure Therapy
Fragmented biographical memory: traumatic experiences are stored as sensory-emotional fragments disconnected from the life narrative. Integration requires placing them in temporal context.
Lay out the lifeline (flowers for good events, stones for traumatic ones), running from childhood through both deployments. Narrate the whole life in order, not only the stones, so the fragments have a biography to be placed back into. The therapist writes the narration down and reads it back across sessions; the finished testimony is signed.
"We're going to lay out your lifeline. Place this flower for a time you felt safe. This stone for something painful. Start from the beginning."
Where Approaches Genuinely Disagree
Research shows many complex trauma survivors can process directly. Extended stabilization may reinforce avoidance.
Rushing to process with a fragmented system is dangerous. The parts need to trust the process first.
Trauma created maladaptively stored memories driving symptoms. Reprocess the memories.
The nervous system adapted to survive. These aren't maladaptive: the body needs to complete what it started.
Philosophical Lenses
These are not treatment plans. They are ways of seeing — philosophical perspectives that illuminate aspects of this case that clinical modalities may not address directly.
For Levinas, the face of the Other is not an experience one can choose to have or refuse. It is the originary ethical event: prior to consciousness, prior to freedom, prior to any decision to engage. Darius's numbing does not refuse the face; nothing can. What has happened is that the conditions of his life (combat, childhood violence, institutional betrayal) have produced a subject so organized around survival that the ethical demand the face makes cannot be received as anything other than threat. His partners said he was 'impossible to reach,' but Levinas would reframe this: Darius is not withholding himself. He has been shaped into a subject for whom proximity to the Other is indistinguishable from annihilation. The asymmetry matters here: Levinas's ethics is not about mutual vulnerability. The therapist's responsibility toward Darius is infinite and non-reciprocal. It does not depend on Darius being ready.
Darius is a Black veteran. His trauma did not begin in combat. Fanon would insist on locating individual psychological injury within the colonial and racial structures that produced it: the military as an institution that extracts bodies from marginalized communities, sends them to war, and returns them to a society that will then pathologize their responses. His hypervigilance may be as much a response to ongoing racial threat as to combat memory. Treating Darius without addressing the racist structures that shape his daily life treats the symptom and ignores the wound.
Herman would see Darius's presentation as textbook complex PTSD: not a single traumatic event but the cumulative effect of prolonged exposure to overwhelming experience in conditions of captivity or powerlessness. The military context provided both the trauma and the conditions that prevented its processing: enforced helplessness, institutional betrayal, mandatory silence. His emotional numbness is a survival adaptation that now prevents connection. Herman's staged model (safety first, then mourning, then reconnection) insists that no trauma processing should begin until Darius has a stable foundation of safety, including addressing the drinking that currently substitutes for it.
Sources & Method
This is a composite fictional case — no real client is depicted. Formulations represent how each modality would typically conceptualize and approach a case with this presentation, based on published clinical literature and training materials. Each formulation draws on the modality's own theoretical framework, key texts, and clinical principles as documented on its modality page. Full source citations for every modality are available on the Sources page.