Trauma & recovery

When the Trauma Started Early

Harm that happened once is treated differently from harm that happened for years, inside the relationships that were supposed to keep you safe.

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A different shape of injury

Most of what the public knows about PTSD is built on the single-incident model: a discrete event, a memory that intrudes, a set of reminders to be avoided. That model describes a great deal of trauma accurately. It describes prolonged, repeated trauma in childhood considerably less well.

Herman (1992) made this argument directly, proposing that survivors of prolonged and repeated trauma present with a syndrome broader than classical PTSD, one that includes disturbances in affect regulation, in identity, and in the capacity to sustain relationships, alongside the intrusion and avoidance symptoms already recognised.

What it tends to look like

People carrying this often do not arrive describing a memory. They arrive describing a pattern. Relationships that end the same way each time. A sense of being fundamentally unlike other people. Difficulty naming what they feel, or knowing it only as a general physical unease. A nervous system that has never quite stood down. Anger that arrives either far too late or far too fast.

Because none of that looks like the textbook picture, it is frequently treated as a personality problem, by clinicians and by the person themselves.

The treatment question this raises

If the injury includes the capacity to regulate emotion and to be in relationships, does it make sense to go straight at the trauma memory? This has been tested rather than argued about.

Cloitre and colleagues (2010) randomised women with childhood-abuse-related PTSD to one of three sequences: a skills phase focused on affect regulation and interpersonal functioning followed by prolonged exposure, that skills phase followed by supportive counselling, or supportive counselling followed by prolonged exposure. The skills-then-exposure sequence produced the highest proportion of full remissions, and was superior in reducing problems with emotion regulation, anger expression and interpersonal difficulties.

The finding is not that exposure should be avoided in this population. It is that the order matters, and that building the capacity to tolerate strong feeling before going toward the memory produces better results than doing either alone.

Why the risk factors line up

This also fits the epidemiology. In the meta-analysis by Brewin and colleagues (2000), reported childhood abuse was among the risk factors with the most uniform predictive effect on adult PTSD, alongside psychiatric history and family psychiatric history. Early harm does not simply cause distress at the time. It changes how later events land.

What to take from it

If you recognise yourself here, two things follow. The work is likely to be slower than a twelve-session protocol, and slower is not the same as failing. And the early phase, which can feel like it is not addressing the real problem, is doing something the trial evidence says is load-bearing.

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