Complex Relational Trauma

Darius, 34, veteran, currently unemployed

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."

History

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.

Clinical note: Darius presents with both developmental trauma (childhood abuse) and combat trauma — a combination the VA/DoD CPG (2023) and NICE (NG116) both address, though they privilege different protocols. CPT and PE have the strongest RCT evidence for PTSD (NICE: 'recommended'; APA: 'strongly recommended'). However, Darius's childhood history and emotional numbing suggest the work may need to address developmental attachment injuries that standard PTSD protocols were not designed for (Cloitre et al., 2010). STAIR-NST was developed specifically for this — skills first, then narrative. The drinking complicates treatment: some evidence supports concurrent trauma-substance treatment (Seeking Safety, Najavits, 2002), while some programs require sobriety first. Adaptive Disclosure (Litz et al., 2021) is the only protocol that differentiates combat wound types — life-threat, loss, and moral injury — which may be critical for Darius.

Where Approaches Genuinely Disagree

Stabilize first or process directly?
Prolonged Exposure

Research shows many complex trauma survivors can process directly. Extended stabilization may reinforce avoidance.

vs.
IFS

Rushing to process with a fragmented system is dangerous. The parts need to trust the process first.

Is this a disorder or an adaptation?
EMDR

Trauma created maladaptively stored memories driving symptoms. Reprocess the memories.

vs.
Somatic Experiencing

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.


11 Formulations

Select 2–3 modalities to compare side by side:


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.