THE PROMISE OF ATTACHMENT-BASED COUPLE INTERVENTIONS FOR 
INDIVIDUALS LIVING WITH CPTSD  

By  

Jennifer White VanBoxel 

A DISSERTATION 

Submitted to 
Michigan State University 
in partial fulfillment of the requirements   
for the degree of 

Human Development and Family Studies – Doctor of Philosophy 

2023 

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ABSTRACT 

Complex Post Traumatic Stress Disorder (CPTSD) is a leading mental health concern, 

which is known to be the most prevalent and functionally impairing form of traumatic stress 

diagnosis. CPTSD results from prolonged and repeated forms of interpersonal trauma, such as 

physical, sexual, mental, or emotional abuse. CPTSD includes PTSD symptoms in addition to a 

cluster of symptoms indicating a Disorganized Sense of Self (DSO), which includes pervasive 

disturbances in relationships. CPTSD symptomology is known to have a degenerating impact on 

intimate relationships; however, the mechanisms are yet to be explored within the population 

itself. Further, prior research exploring how couples experience and manage CPTSD symptoms 

is limited. Empirical research on systemic family therapy and traumatology identify the potential 

fit of expanding attachment-based relational interventions for CPTSD populations—most 

notably, Emotionally Focused Therapy (EFT) with couples. For this study, couples active in EFT 

treatment, and where at least one partner met the criteria for CPTSD, were recruited to 

participate in a joint semi-structured qualitative interview. Framework analysis was used to 

analyze the data for two separate studies. Study one explored couples’ joint experience of 

CPTSD symptomology present within the relationship. Participants’ experiences of symptoms 

and their perceptions of how CPTSD impacted their relationship along with their methods of 

coping were described. Study two examined couples’ experiences of EFT in the context of 

CPTSD symptoms, and it analyzed participants’ perspectives regarding the fit and acceptability 

of EFT for treating interpersonal trauma-related distress within their relationships. Implications 

for future research and clinical recommendations are discussed.  

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Copyright by 
JENNIFER WHITE VANBOXEL 
2023 

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This dissertation is dedicated to all survivors of interpersonal trauma who do the hardest and 
most important work there is, and despite all odds, strive to create a truly safe and loving space 
in the world for themselves and others. 

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ACKNOWLEDGEMENTS 

First, I would like to acknowledge the participants of this study who shared their 

experience so they could help expand the empirical understanding of CPTSD and promote ever 

more accessible and potent interventions for survivors of interpersonal trauma. Second, I would 

like to acknowledge the therapists who not only provided essential support for the recruitment 

efforts of this study, but who work diligently to serve interpersonal trauma populations through 

attachment-based systemic therapy.  

To my mentors at Michigan State University, Adrian Blow, Andrea Wittenborn, and 

Kendal Holtrop, and at Kansas State University, Briana Nelson Goff, I would like to thank you 

for your passionate and expansive work in the field of systemic therapy which has instructed, 

enriched, and inspired me. All of your support and belief in my passion for treating CPTSD 

within systemic therapy has been invaluable. Thank you all for allowing me to learn from you 

and for providing me with so many incredible opportunities to learn and develop as a researcher, 

systemic therapist, and instructor.  

To my family, and friends who have loved and supported me through this process, my 

listening ears who have cheered me on, given me space to enjoy life outside of my work, and 

who have reminded me who I am through all of the struggle, but especially and most of all, 

through our shared joy.  

To my dear friends and esteemed colleagues at MSU, Deb Miller, Patricia Huerta, Finn 

Muzzy, and Paul Lepley; all of your humanity, brilliance, genuine integrity, and joy were a light 

in the darkness and will forever warm my spirit and give me a sense of home, ‘we are family’.  

To the MSU center for survivors, your resources supported me and empowered me to 

regain my voice.  

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Mom and dad, you worked to educate me in the way that I needed, even when no one 

believed in you, and taught me that following my intuition can be my greatest strength. Your 

genuine love and unwavering belief in me gave me the confidence to persevere through anything 

and work towards my passions.  

Finally, to Andrew and Ralph, our family my safest place and you put true purpose and 

joy into my life. This journey has been nothing but a joint family effort. Nothing means more to 

me than the quality of our connection; thank you for giving me the honor and opportunity to be 

your partner, Andrew, and your mommy, Ralph.   

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TABLE OF CONTENTS  

LIST OF TABLES ....................................................................................................................... viii 

LIST OF FIGURES ....................................................................................................................... ix 

CHAPTER 1: INTRODUCTION TO THE STUDY...................................................................... 1 

CHAPTER 2: LITERATURE REVIEW ...................................................................................... 16 

CHAPTER 3: METHODOLOGY ................................................................................................ 36 

CHAPTER 4: STUDY ONE—COUPLES’ EXPERIENCES OF CPTSD 
SYMPTOMATOLOGY ............................................................................................................... 60 

CHAPTER 5: STUDY TWO—COUPLES’ EXPERIENCES OF EMOTIONALLY FOCUSED 
THERAPY IN THE CONTEXT OF CPTSD SYMPTOMOLOGY .......................................... 120 

REFERENCES ........................................................................................................................... 177 

APPENDIX A: RECRUITMENT FLYER ................................................................................. 190 

APPENDIX B: INFORMED CONSENT FORM ...................................................................... 191 

APPENDIX C: CLIENT SCREENING SURVEY .................................................................... 195 

APPENDIX D: DEMOGRAPHIC SURVEY ............................................................................ 203 

APPENDIX E: THERAPIST SCREENING QUESTIONNAIRE ............................................. 209 

APPENDIX F: INTERNATIONAL TRAUMA QUESTIONNAIRE ....................................... 213 

APPENDIX G: SEMI-STRUCTURED INTERVIEW GUIDE ................................................. 218 

APPENDIX H: STUDY ONE—FRAMEWORK MATRIX ..................................................... 225 

APPENDIX I: STUDY TWO—FRAMEWORK MATRIX ...................................................... 230 

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LIST OF TABLES 

Table 1 Participant Demographics ................................................................................................ 46 

Table 2 Participant ITQ Scores ..................................................................................................... 49 

Table 3 Framework Matrix ......................................................................................................... 225 

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LIST OF FIGURES 

Figure 1 Recruitment Flyer ......................................................................................................... 190 

Figure 2 International Trauma Questionnaire ............................................................................. 214 

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CHAPTER 1: INTRODUCTION TO THE STUDY 

Statement of the Problem 

Science indicates that close and fulfilling human relationships are a critical factor in 

survival, health, longevity, and well-being (Fyvie et al., 2019; Gerge, 2020; Mahoney et al., 

2019; Matheson & Weightman, 2020). However, for individuals who have been exposed to 

severe and prolonged interpersonal trauma, close human relationships coexist as both necessary 

and damaging (Hyland et al., 2017b; Matheson & Weightman, 2020; Stadtmann et al., 2018). 

Clinical symptomology that develops from such trauma, Complex Post Traumatic Stress 

Disorder (CPTSD), is rooted in prolonged and repeated interpersonal traumas such as adverse 

childhood experiences (ACES), childhood sexual abuse, emotional abuse, and prolonged 

domestic violence (Knefel, 2019; Melton et al., 2020). Unfortunately, these types of trauma are 

extremely common worldwide (Hyland et al., 2017a), and according to recent prevalence studies, 

so is CPTSD (Karatzias et al., 2017; Redican et al., 2022b). Overwhelmingly, research shows 

that the prolonged effects of CPTSD are devastating (Karatzias et al., 2018a; Mahoney et al., 

2019; Matheson & Weightman, 2020; Ogawa et al., 1997). CPTSD has a severe and detrimental 

impact on well-being, relationships, psychological health, physical health, and mortality for 

millions of people globally (Cloitre, 2021; Hyland et al., 2017a; Karatzias et al., 2017; 2019a). 

As a result, CPTSD has become a leading epidemiological concern for professionals in mental 

health-related fields, including at the World Health Organization (Hyland et al., 2017b).  

The primary focus in the traumatology field at this time lies in addressing the critical 

empirical gap in evidence-based interventions for CPTSD (Cloitre, 2021; Karatzias et al., 

2019b). Existing traumatic stress interventions were developed for and have been empirically 

tested to treat Post Traumatic Stress Disorder (PTSD), which, though related and serious, is now 

1 

known to be categorically distinct from CPTSD (Herman, 1992; Hyland et al., 2017a). Research 

shows that evidence-based interventions for PTSD do not adequately address the therapeutic 

needs of CPTSD populations (Matheson & Weightman, 2020; Monson et al., 2022; Karatzias et 

al., 2019c). Though by definition, the CPTSD diagnosis includes PTSD symptomology, there are 

three additional symptom clusters defined as Disturbances in Self Organization (DSO) that 

intensify and alter the traumatic stress response (Herman, 1992; Hyland et al., 2017b). DSO 

symptoms consist of emotion-regulation difficulties, negative self-concept, and disturbances in 

relationships (Cloitre, et al., 2018). These symptoms set CPTSD apart from the traditional 

understanding of traumatic stress response and identify the inherent and severe fractures in 

interpersonal attachment that are present for CPTSD populations (Karatzias et al., 2018b).  

Individuals with CPTSD suffer from a disorganized ability to regulate emotions and 

positively relate to themselves and others (Karatzias et al., 2018a; 2018b; Knefel et al., 2019). 

This makes relationships extremely distressing and leaves those with CPTSD in a perpetual cycle 

of re-traumatization (Alexander, 2012; Karatzias et al., 2019a). Therefore, current calls for 

research acknowledge that “one size does not fit all” in terms of trauma intervention (Fyvie et al., 

2019; Gerge, 2020). Clinical observation from both the couple therapy and the traumatology 

fields have recognized the importance of expanding current CPTSD interventions to include 

relational interventions, but the two fields have been largely operating in isolation (Brewin, 

2020; MacIntosh, 2018). Researchers recognize the need for a better understanding of what 

individuals with CPTSD experience in relationships and how to tailor interventions to best 

address the devastating impact of CPTSD’s specific symptomology (Karatzias & Cloitre, 2019; 

Karatzias et al., 2019b; Matheson & Weightman, 2020). 

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Importance of Categorizing CPTSD as a Distinct Diagnosis  

Defining CPTSD as a distinct disorder. The mental health field has long recognized the 

negative impact of traumatic stress response on individuals exposed to trauma (Herman, 1992; 

Melton et al., 2020). For over forty years, PTSD has been the primary traumatic stress diagnosis 

from which clinicians and researchers operate to test and develop effective therapeutic 

interventions (Cloitre et al., 2011; Melton et al., 2020). The PTSD diagnosis itself consists of 

three core symptoms, which include reexperiencing, hypervigilance, and avoidance (Hyland et 

al., 2017b). As operationalized by the International Classification of Diseases, eleventh edition 

(ICD-11), DSO symptom clusters—which, in addition to PTSD symptomology make up the 

CPTSD diagnosis—include emotion regulation difficulties, disturbances in relationships, and 

negative self-concept (Cloitre et al., 2018; Hyland et al., 2017; McLaughlin et al., 2015).  

CPTSD impact and outcomes. The impact of untreated CPTSD is severe. In 1992, 

Herman determined “three broad areas of disturbance which transcend simple PTSD” that 

remain salient today (p. 379). These areas of disturbance include, first, symptoms that are now 

classified as DSO; second, categorical differences of the impact of trauma type on “deformations 

of relatedness and identity,” and third, CPTSD survivors’ vulnerability to revictimization 

(Herman, 1992, p. 379). Recent studies have explored Herman’s clinical observations and found 

that persons with CPTSD are at a higher risk for revictimization than those with PTSD or the 

general population (Knefel et al., 2019). The cycle of revictimization, and the ongoing 

symptomology of hyperactivation and psychological burden, are known to have a deteriorating 

effect on brain structure and individual relational capacities, along with mental and physical 

health (Alexander, 2012; Harricharan et al., 2016). CPTSD and associated interpersonal traumas 

are highly correlated with early death and great psychological distress during one’s lifetime 

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(Hyland et al., 2017a). Further, CPTSD is heavily linked to negative health and interpersonal 

outcomes, including a wide range of comorbidities including severe dissociation, chronic illness, 

functional impairment, job loss, domestic violence, sexual assault, suicidality, and relational 

distress (Brenner et al., 2019).  

CPTSD and intimate relationships. Studies reflect the degenerative effects of CPTSD 

on intimate relationships (Courtois & Ford, 2012; Herman, 1992; Hyland et al., 2017a; 2017b). 

Due to engrained attachment patterns and neurobiological changes in the brain resulting from 

severe and/or accumulated interpersonal traumas, individuals with CPTSD struggle with intimate 

relationships above and beyond those individuals with PTSD alone (Courtois & Ford, 2012; 

Dugal et al., 2020). As discussed, the differentiation in trauma type and resulting symptomology 

are the primary cause for classifying CPTSD disorder, and across studies, the severity of the 

relational impact of CPTSD is at the forefront (Baldwin, 2013). Intimate relationships experience 

severe strain in the context of CPTSD and are more likely to result in divorce, separation, or 

long-term distress compared to PTSD and general populations (Aloni et al., 2020; Hyland et al., 

2017a, 2017b; 2018).  

CPTSD is a challenging disorder for individuals and has a severe life impact. In this 

study, I explored the impact of CPTSD on intimate relationships. Next, I will turn to theory to 

show its importance for understanding the relationship between trauma and interpersonal 

relationships.  

Theoretical Framework 

An important consideration in this study is the use of two theoretical frameworks, 

attachment theory and polyvagal theory, which will provide a scaffolding for the analysis of this 

study (Bowlby, 1988; Porges & Furman, 2011). Each of these theories are well aligned with the 

4 

 
 
 
interpersonal trauma literature, and they are important foundations for CPTSD research and 

intervention efforts.  

Attachment theory. Developed by psychiatrist John Bowlby (1988), attachment theory 

examines the universal and biological necessity of bonding throughout human development. 

Initially focused on child development and more recently expanded to adults (Aloni et al., 2020; 

Hazan & Shaver, 1987; Nivison et al., 2022), attachment theory maintains that attachments, 

which are defined as close intimate bonds with attachment figures (i.e., parents, caregivers, 

intimate partners, and close others), function to protect and support individuals during times of 

need or stress. Attachment figures provide a safe and “secure base” from which individuals can 

“explore their environment effectively” (Alexander, 1992, p. 185). The mechanisms of 

attachment theory address how humans encode patterns of interaction and bond with current and 

future attachment figures based on the relational signals they receive over the course of 

development (Cassidy & Mohr, 2001). Stemming from the intrapsychic encoding of relational 

patterns, Bowlby identified four attachment styles: secure attachment, anxious attachment, 

avoidant attachment, and disorganized attachment (Alexander, 1992; Bowlby, 1988).  

Secure attachment is characterized as a way of relating to others that reflects an encoded 

sense of interpersonal security in which an individual can seek proximity to others who are close 

and can feel assured that overall, their emotional and physical needs will be met (Atkinson, 

1997). Conversely, anxious attachment reflects an encoded pattern of expecting forms of neglect 

or abandonment from otherwise secure attachment figures, which is exhibited by hypervigilance 

and excessively seeking emotional proximity due to a fear of loss in close relationships. 

Avoidant attachment is characterized by the conscious and subconscious avoidance of emotional 

closeness and proximity in attachment relationships due to expectations of emotional or physical 

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harm. Finally, disorganized attachment is understood to be a way of relating that integrates both 

anxious and avoidant attachment and a stern emotional disengagement from others due to 

encoded patterns of neglect or abandonment in which attachment figures are not otherwise 

trustworthy, safe, or secure (Alexander, 1992; Atkinson, 1997; Bowlby, 1988; Hazan & Shafer, 

1987).  

Attachment and CPTSD. Due to a pervasive pattern of interpersonal trauma, individuals 

with CPTSD possess a multiplex of attachment wounds that are connected to intrusive 

reexperiencing (of traumatic memories), avoidance, and the hypervigilance features of PTSD. 

Simultaneously, those with CPTSD have difficulty regulating emotions, they struggle with self-

defeating negative appraisals and beliefs about themselves, and they have difficulties 

establishing a secure base in relationships. As outlined by Liotti (2004), relationally traumatized 

individuals often develop an internal polarization of attachment-related phobias, which are 

characterized as the phobia of attachment and the phobia of attachment loss. These attachment 

mechanisms leave individuals with CPTSD in a revolving state of “unresolvable fear” and 

relational distress with no clear path toward relief. Both individual autonomy and secure bonds 

with others are undermined by conflicting attachment patterns, making even the most positive 

intimate relationships psychologically distressing and difficult to maintain. Disorganized 

attachment related to interpersonal traumas leave an individual managing “nonintegrated mental 

states,” characterized by seemingly unsolvable relational exchanges, and no safe place to land 

internally or externally (Liotti, 2013, p. 1136). 

Polyvagal theory. Porges’ polyvagal theory (2009), which is supported by other studies 

on the neurobiological factors of neuroception, describes the process by which individuals 

physiologically appraise risk and safety in their environments (Baldwin, 2013). Dependent upon 

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neurobiological appraisals, individuals experience a state of calm relatedness to others in their 

environment, or hyperactivation within the autonomic nervous system. As noted by Gerge 

(2020), the relational capacities of the prefrontal cortex dim amidst a perceived sense of threat, 

and the brain, along with the body, slips into a defensive state of fight, flight, freeze, or fawn 

response patterns. Studies show that individuals who exhibit severe insecure attachment or 

CPTSD, and who have been exposed to related accumulative traumas, tend to experience 

ongoing distrust, distance, and distress in relationships even once they are safe from harm 

(Baldwin, 2013). The cycle of dissociation and hyperactivation persists due to physical changes 

in the hippocampus and amygdala that impair an individual’s ability to accurately appraise safety 

in relationships. These mismatched appraisals lead to either an over- or under-assessment of risk 

in the context of relationships, causing either undue distress, fear, and defensiveness, or an 

elevated and unrealistic sense of calm amidst danger (Porges, 2009). Furthermore, these changes 

in the hippocampus impair an individual’s ability to connect to their own internal experience, 

making it difficult to understand or communicate what is happening (Gerge, 2020). Therefore, 

when bonding is disorganized and overwhelmed by conflicting intrapsychic and autonomic 

signals of danger, individuals struggle to reap the protective benefits of close relationships, even 

despite their best efforts (Stadtmann, 2017; 2018).  

Gaps in the Literature  

Current state of CPTSD interventions. Due to the complex relational nature of 

CPTSD, researchers and clinicians suggest phase-based relational treatments (Cloitre et al., 

2011; Courtois, & Ford 2012) that integrate family members as social supports (Monson et al., 

2022; Stadtmann et al., 2017; 2018). The recommendation of phase-based treatments comes 

from the collective recognition from both clinicians (Cloitre et al., 2011) and researchers 

7 

 
 
 
(Karatzias et al., 2019b) that individuals with CPTSD do not reach a point of recovery after one 

form or method of treatment (Mahoney et al., 2019). Due to the multifaceted impact of 

symptoms, treatment recommendations for individuals with CPTSD hypothesize that 

interventions should address individualized needs in a sequenced manner to increase 

acceptability and effectiveness in the long and short term (Cloitre et al., 2011; 2020a, 2020b). 

For example, this theory suggests that initial sequences or phases of treatment should target 

stabilization and safety, if not already present, and then move toward interventions such as 

emotion or memory processing (Cloitre et al., 2011). Overall, the idea is to address issues first 

that will allow treatment to progress (e.g., stabilization and safety), and then continue to address 

other needed aspects of treatment which include intrapsychic memory processing to alter their 

fear-based relationship to the trauma stimulus, in the case of CPTSD, interpersonal relationships. 

Further, CPTSD clinicians and researchers highlight the importance of treating the disturbances 

in relationships component of the DSO cluster due to its ability to undermine progress in all 

other areas and its ability to secure an individual’s sense of safety both within and outside of 

therapy (Cloitre, 2021; Coleman et al., 2021). In this sense, integrating family or meaningful 

social supports using a relational framework of care is recommended and shows great promise 

for this population (Cloitre et al., 2020b; Matheson & Weightman, 2020; Stadtmann, 2017; 

2018). However, phase-based treatments stand as a theoretical recommendation, and no current 

studies have tested the use of these treatments. Furthermore, many questions remain regarding 

the best ways to sequence treatments (Cloitre et al., 2020). Researchers hypothesize that the 

breach in safety within close relationships both leads to and exacerbates other mental health 

symptoms and must be addressed to spark lasting clinical change (Hyland, 2017; Johnson, 2019; 

Matheson & Weightman, 2020; Stadtmann et al., 2018). Despite this understanding, the 

8 

 
 
 
relational component is an understudied area of CPTSD research, leaving a dearth of literature 

on the subject of how individuals with CPTSD experience the disorder, relationships, and 

interventions (Karatzias et al., 2019b. Interpersonal factors are at the helm of CPTSD 

development and symptomology; therefore, to move interventions forward for CPTSD 

populations, questions about the impact of CPTSD on relationships and relationships on CPTSD 

must be explored (Courtois & Ford, 2012; Stadtmann, 2017; 2018).  

Empirical evidence in CPTSD treatment. The current standard of care for trauma relies 

most heavily on exposure-based or trauma-informed cognitive behavioral interventions intended 

to treat the three clusters of PTSD symptomology (De Jongh et al., 2016; Karatzias et al., 2019). 

These traditional interventions for traumatic stress are not as effective for CPTSD and leave 

many without effective or lasting care (Matheson & Weightman, 2020; Melton et al., 2020). 

Empirical evidence suggests that current traumatic stress interventions fall short due to their lack 

of capacity to address DSO symptomology either in addition to or prior to targeting PTSD 

symptoms, which usually consists of traumatic memory processing or skills training (Cloitre et 

al., 2020). Such interventions can pose too much of a burden on CPTSD populations without 

providing them with the proper amount of intrapsychic and interpersonal support, which is 

usually fragile due to ongoing DSO symptoms.  

A recent meta-analysis by Mahoney et al. (2019) provided an in-depth review of 

treatment effects and outcomes for symptoms and trauma types associated with CPTSD. The 

review included studies that address CPTSD sequela that were deemed rigorous in terms of 

methodology and approach (2019). This analysis found that trauma memory processing was 

significantly effective in reducing trauma symptoms compared to usual care; however, other 

aspects of trauma interventions, such as psychoeducation and emotion regulation skills training, 

9 

 
 
 
were nonconclusive (Mahoney et al., 2019). Importantly, this review also determined the initial 

effectiveness of group interventions that incorporate social support but noted the necessity for 

further scientific inquiry in this area.  

Relational interventions for traumatic stress. Couple interventions have shown 

promise in treating individual mental health disorders such as depression, anxiety, obsessive 

compulsive disorder, eating disorders, schizophrenia, substance abuse, and post-traumatic stress 

(Baucom, et al., 1998; 2012; 2014; Doss et al., 2022). In one review, Fisher et al. (2016) found 

that couple interventions can be as effective as individual therapy, with the added benefit of 

increased relationship functioning. For example, a randomized control trial conducted by 

Wittenborn et al. (2018) found that a leading attachment-based couples’ intervention (i.e., 

Emotionally Focused Therapy) was significantly more effective than usual care in treating 

individual depression and relationship satisfaction. In the context of traumatic stress, a recent 

review found that couple therapy can be effective in lowering trauma symptoms for individuals 

with PTSD (Suomi et al., 2019).  

Developing support indicates that dyadic intervention for traumatic stress is effective in 

treating relational functioning and trauma symptoms for trauma-exposed populations (Monson et 

al., 2022; Oseland et al., 2016). Dyadic or couple interventions for traumatic stress have four 

current domains, which include disorder-specific couple therapy, partner-assisted interventions, 

general couple therapy, and psychoeducation and family engagement in therapy (Monson et al., 

2022). Each type of couple intervention for traumatic stress involves various models of therapy 

(Monson et al., 2022); however, common factors of care include an awareness of the systemic 

impact of trauma within the couple relationships (Nelson Goff & Smith 2005; Oseland et al., 

2016). The couple adaptation to traumatic stress (CATS) model developed by Nelson Goff and 

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Smith (2005) highlights the systemic impact of traumatic stress within couple relationships. 

According to the CATS model, acute individual functioning in response to trauma symptoms for 

survivors and their partners interacts with predisposing factors, and couple functioning factors 

such as attachment and stability indicate how couples adapt to traumatic stress symptomology. 

Oseland et al. (2016) used the CATS model to identify key clinical components of couple 

interventions with trauma-exposed couples across models. Findings from this study indicated 

four essential clinical components of a traumatic stress intervention with couples: individual 

safety and stability, couple safety and stability, conjoint trauma processing, and connection 

between partners. These core clinical components were believed to support recovery for trauma 

survivors across couple therapy models (Oseland et al., 2016). Furthermore, the involvement of 

partners in trauma treatment can support sustainable outcomes by treating trauma within the 

context of the system rather than isolating treatment to the individual (Baucom et al., 1998; 

2012; 2014; Blow et al., 2020). 

Overall, the inclusion of intimate partners in treatment acknowledges the reality that 

clients and their symptoms do not operate in isolation but rather exist within a relational system 

(Banford Witting & Busby, 2019; Baucom et al., 1998; 2014; Doss et al., 2022; Kozlowska, 

2020). Couple therapy for individual disorders enables clinical interventionists to leverage the 

intimate relationship as a mechanism of change by establishing mutual support and a secure base 

from which partners can explore new patterns of interacting, process past wounds, and adapt new 

mental/emotional skillsets (McRae et al., 2014). Areas of growth in couple therapy for individual 

disorders include determining fit and acceptability of couple treatments for specific individual 

disorders like CPTSD, and determining salient mechanisms of change (Baucom et al., 1998; 

2014; Blow et al., 2020; Costa-Ramalho et al., 2017; Johnson, 2003).  

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Emotionally focused Couple Therapy. The systemic family therapy field has identified 

an inherent value of systemic conceptualization and intervention for traumatic stress response 

(MacIntosh & Whiffen, 2005; Macintosh & Johnson, 2008; MacIntosh, 2018; Monson et al., 

2022). Further, the systemic approach in this sense is especially salient for those with 

accumulated interpersonal trauma histories and ongoing distress in relationships captured by 

CPTSD (MacIntosh, 2018; Roundy, 2017; Suomi et al., 2019; Vaillancourt-Morel et al., 2019). 

Much of the work in this area has been explored with Emotionally Focused Couple therapy 

(EFT) with promising preliminary evidence (Dalton et al., 2013; Johnson, 2019; Roundy, 2017). 

EFT is an experiential and attachment-based intervention that harnesses present process and 

emotional enactments to establish new emotional connections and patterns between partners 

(Johnson, 2003; 2019). Studies on EFT maintain that mechanisms of change are contingent upon 

this experiential process that enables partners to develop emotional attunement and a safe and 

secure attachment (Wiebe & Johnson, 2016). 

The bulk of empirical and clinical support for using EFT to treat PTSD/CPTSD exists in 

the form of case examples (Johnson, 2002; MacIntosh, 2008), extensive theoretical discussions 

on the proposed fit of EFT for CPTSD (Johnson, 2002; Roundy, 2017), and one randomized 

clinical trial with adult survivors of childhood sexual assault, which is highly linked to CPTSD 

(Dalton et al., 2013). These studies have emphasized the clinical perspectives of therapists who 

worked with severely interpersonally traumatized clients, clients who struggle with “relationship 

trauma and terminal relational distress” and who experience significant change from EFT 

(Johnson, 2002, p. 65). Theoretical discussions of EFT for interpersonal trauma survivors have 

been especially notable, as multiple studies and texts define in detail how the attachment-based 

mechanisms of EFT target insecure attachment and resulting mental health symptomology 

12 

 
 
 
caused by severe interpersonal trauma (Roundy, 2017; Wiebe & Johnson, 2016; Wiebe et al., 

2017). Some preliminary studies have been conducted with populations with a wide range of 

traumas (Dalton et al., 2013; MacIntosh, 2014). However, these studies were not conducted with 

a CPTSD-specific population, and more evidence is needed to determine the true fit of EFT for 

CPTSD as a distinct diagnosis.  

Though there is a promising body of literature pointing to the fit and utility of further 

testing the EFT intervention for CPTSD populations, this literature also acknowledges that 

CPTSD symptoms can also make it difficult for survivors to fully engage in the EFT process 

(MacIntosh & Johnson, 2008). Therefore, some recommend adaptations to EFT for CPTSD 

populations, including a longer duration of treatment and increased assessment (Johnson, 2002). 

However, these recommendations come from a clinical perspective, and there is no information 

in the literature examining how individuals with CPTSD experience components of the EFT 

intervention, or what changes to the EFT protocol are best suited to CPTSD populations.  

The need for qualitative inquiry into candidate CPTSD interventions. With the 

recent definitive diagnostic criteria from the ICD-11, current studies acknowledge the 

importance of developing a comprehensive understanding of how individuals with CPTSD 

experience the disorder so the mental health field can appropriately adapt effective interventions 

(Melton et al., 2020; Stadtmann, 2017; 2018). As noted, current evidence-based treatments for 

traumatic stress were developed for PTSD, which does not account for the more severe and 

relational nature of the DSO symptom clusters and root trauma triggers. The main gap is that 

current traumatic stress approaches for CPTSD “rely heavily on clinical experience and theory, 

and there is usually sparse empirical evidence in terms of effects, and acceptability from the 

patient or therapist perspective” (Chouliara & Narang, 2017, p. 3).  

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Despite the clear connection between CPTSD and interpersonal functioning, little is known 

about how individuals with CPTSD and their partners experience, interpret, and manage the 

disorder. Nonetheless, it is known that in addition to the underlying attachment and 

neurobiological factors of CPTSD, studies on interpersonal trauma types reveal that intimate 

partner relationships trigger unresolved interpersonal traumas (Barawi et al., 2020). Therefore, 

calls for future research collectively address the need for deeper inquiry using qualitative 

methods to determine the lived experience of CPTSD populations in addition to learning their 

perspective on the potential fit, acceptability, and adaptation of treatments that directly target the 

underlying intrapersonal and interpersonal factors of CPTSD (Cloitre et al., 2011, 2020a, 2020b; 

Karatzias & Levendosky, 2019, Melton et al. 2020).  

Present Study  

Empirical investigation into CPTSD intervention at this time requires a more 

comprehensive understanding of the interpersonal impact and lived experience of CPTSD 

populations and their families (Melton et al. 2020). This knowledge can expand on the current 

literature, which has identified the potential fit for using relational interventions for CPTSD 

(Cloitre & Karatzias, 2019; Matheson & Weightman, 2020). The purpose of this study is 

twofold. First, it seeks to explore how couples in the context of CPTSD experience interpersonal 

related trauma symptoms in their relationships. Second, despite promising evidence 

that highlights the potential effectiveness of using EFT with CPTSD couples, it is important 

to determine the fit and acceptability of this treatment from a client perspective (Roundy, 

2017; Stadtmann et al., 2018). Therefore, the proposed study will explore the following research 

questions: 

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Research questions. 

R1) How do individuals with CPTSD and their partners experience, manage, and 

perceive the impact of CPTSD-specific symptomology (i.e., reexperiencing, 

hypervigilance, avoidance, disturbances in relationships, emotion regulation difficulties, 

and negative self-concept) within the context of their intimate relationship? 

R2) How do individuals with CPTSD and their partners experience EFT and perceive the 

acceptability of EFT in treating their relationship difficulties; i.e., what do they describe 

as especially helpful or difficult about participating in EFT?  

15 

 
 
 
 
 
CHAPTER 2: LITERATURE REVIEW 

Introduction 

Trauma type and classification. The origin of psychoanalysis, rooted in the work of 

Sigmund Freud, is what many believe to be the early scientific study of complex interpersonal 

trauma response (Herman, 1992; Matheson & Weightman, 2020). One of the key hallmarks of 

Freud’s work was the connection he made between early interpersonal violations, such as 

childhood sexual abuse (CSA), and the resulting symptomology of what was then termed 

‘hysteria’ in adults (Freud, 1953). The mental health field has since worked to distinguish 

between trauma type and response and therefore classify diagnoses that can adequately 

encapsulate the variation of traumatic stress response (Herman, 1992; Hyland et al., 2017a; 

Loitti, 2013).  

For decades, the PTSD diagnosis has been used to distinguish traumatic stress response 

from other mental health diagnoses such as depression and anxiety by classifying reexperiencing, 

hypervigilance, and avoidance as core trauma-related symptomology (Hyland et al. 2017a). 

However, these symptoms fail to address a range of trauma-related symptoms that are more 

prevalent in clinical populations and more closely related to the earlier conceptualizations of 

traumatic stress response (i.e., difficulty regulating emotions, fear in interpersonal relationships, 

and a deteriorated view of oneself) (Courtois & Ford, 2012).  

Herman (1992) originally summarized the consistent reports in clinical literature 

describing an expanded conceptualization of PTSD. The key issue she and others addressed are 

the apparent distinctions between the type of symptomology that develops in response to 

traumatic stress and how these symptoms are predicted by the amount and type of trauma 

experienced. Specifically, individuals who have experienced single event, or non-relational 

16 

 
 
 
 
traumas characterized as “circumscribed traumatic events”—which can include combat, a car 

accident, or a natural disaster—tend to develop PTSD (Herman, 1992, p. 377). However, those 

who have experienced prolonged, repeated, and relationally based traumas (i.e., those perpetrated 

by close others, attachment figures, or individuals/systems with prolonged control over one’s 

survival) tend to develop what is now classified as CPTSD (Palic et al., 2016). The types of 

trauma that are most likely to develop into CPTSD are those that leave individuals with 

“damaging experiences of relationships with others so as to change catastrophically their view of 

themselves, other people, and the wider world” (Matheson, 2016, p 333). Therefore, causes of 

CPTSD include interpersonal trauma with prolonged exposures that vary in nature, are repeated, 

and occur in situations that are difficult to escape. For example, forms of childhood abuse, 

interpersonal abuse, and systemic cultural traumas (e.g., war, displacement, and cultural 

oppression) (Hyland et al., 2017).  

Terminology. The origin of the newly classified CPTSD diagnosis is derived from many 

years of development within the mental health field and its collective concern regarding the 

negative impacts of accumulated traumatic experiences (Courtois & Ford, 2012; Karatzias & 

Levendosky, 2019b). Prior diagnostic proposals for CPTSD sequela have all focused on the 

relational origin of interpersonal trauma and point toward multiple broken attachment bonds over 

time that create a fragmented sense of self that primarily impacts individual well-being and close 

relationships (Ogawa et al. 1997). In efforts to determine a concrete diagnosis, there have been 

several prior labels that sought to identify these phenomena. The prior terms have included 

PTSD, Disorders of Extreme Stress Not Otherwise Specified, Developmental Trauma, Betrayal 

Trauma, and Interpersonal Trauma (Chouliara & Narang, 2017; Gomez et al., 2016; Luxenberg 

et al., 2001). 

17 

 
 
 
The factor that serves as a common thread throughout all of these terms is that they 

acknowledge the presence of accumulated negative experiences with close others that breach the 

boundaries of interpersonal safety (i.e., forms of emotional or physical abandonment, severe or 

chronic mis-attunement, lack of availability [neglect], and/or mistreatment) (Hyland et al., 

2017a). However, a common thread of this trauma typology is that CPTSD sequela are often 

interwoven with positive relational experiences within the same context, leaving a disorganized 

pattern of relating to others and oneself (Liotti, 2004; Pearlman et al., 2005). Relational traumas 

are typically nuanced and therefore tricky to address as they also leave behind a complex 

constellation of symptoms (Luxenberg, et al. 2001). In addition to impairing PTSD symptoms, 

individuals with CPTSD manage “persistent and pervasive impairments in self and relational 

functioning, including difficulties in emotion regulation, beliefs about oneself as diminished, 

defeated or worthless, and difficulties in sustaining relationships” (Maercker, et al.,  2013, p. 

200).  

Measurement. The six-factor model of the CPTSD diagnosis, which includes the three 

core PTSD symptoms and three Disorganized Sense of Self (DSO) symptoms, has been validated 

across studies and global populations (Cloitre, 2018; Tay et al., 2018). The validity of the six-

factor structure supports the clinical utility of differentiating between PTSD and CPTSD as 

distinct disorders (Karatzias et al., 2018a; Tay et al., 2018). The International Trauma 

Questionnaire (ITQ) (Cloitre et al., 2018) was developed to measures levels of PTSD and 

CPTSD symptomology based on the presence of PTSD and DSO symptoms. To qualify for 

CPTSD, individuals must meet the clinical cutoff for PTSD, at least one DSO symptom, and they 

must experience symptoms as persistent, intrusive, and impairing in daily life (Cloitre et al., 

2018; Karatzias et al., 2018a).  

18 

 
 
 
Prevalence and risk of CPTSD. Risk factors that predict CPTSD class membership 

include being female, experiences of poverty, revictimization, and accumulated interpersonal 

trauma (Hyland et al., 2017; Redican et al., 2022a). Moderators for CPTSD include social 

support and emotion regulation skills (Karatzias et al., 2018b; 2019a; Knefel et al., 2019). A 

recent population-based study in the United States found that of a nationally representative 

sample, 3.8% met the criteria for CPTSD, which is similar to results from preliminary studies in 

other countries (Cloitre et al., 2019). Additionally, a key finding is that CPTSD prevalence is 

higher than PTSD across populations (Karatzias et al., 2017a; Redican et al., 2022b). 

Furthermore, the prevalence for CPTSD is extremely high in trauma-exposed and treatment-

seeking populations, ranging between 13% and 80% (Hyland et al., 2018b; Letica-Crepulja et al., 

2020). Across studies, interpersonal trauma and resulting CPTSD symptomology are each 

viewed as the greatest risk factors for mental, physical, and interpersonal health outcomes 

(Benjet et al., 2016; Brenner et al., 2019; Cloitre et al., 2019; Hyland et al., 2018b; Karatzias et 

al., 2017a, 2018b, 2019a; Knefel et al,, 2019; Letica-Crepulja et al., 2020). Furthermore, studies 

assessing risk and protective factors for CPTSD and interpersonal trauma recommend that 

mental health resources should be dedicated to victims of interpersonal trauma due to the 

severity of associated risks and the call for family-based interventions that can address relational 

issues specific to interpersonal trauma populations (Benjet et al., 2016).  

Purpose and aims of differentiating between PTSD and CPTSD. The recent updates 

to the ICD-11 (Brewin, 2020) offer a new way of classifying trauma response in order to address 

two aims: (1) to more accurately define the distinct presentations of trauma symptomology 

between simple PTSD and complex PTSD, and (2) to determine and adapt interventions to 

address the specific therapeutic needs of CPTSD populations (Cloitre et al., 2019). The first aim 

19 

 
 
 
acknowledges the clinical reality that therapists and mental health practitioners have encountered 

for decades in terms of the variation in traumatic stress response (Cloitre et al., 2011), which has 

now been defined by the ICD-11. In combination with definitive diagnostic criteria from the 

ICD-11, current empirical literature has collectively acknowledged the necessity of developing a 

comprehensive understanding of how individuals with CPTSD experience the disorder so that 

the mental health field can appropriately adapt effective interventions (Melton et al., 2020; 

Stadtmann et al., 2017; 2018). This leads to the second aim, which highlights the clinical gap in 

effective CPTSD interventions. As noted, current evidence-based treatments for traumatic stress 

were developed for PTSD, which does not account for the more severe and relational nature of 

the DSO symptom clusters and attachment -based trauma triggers. 

Theoretical Framework of CPTSD  

Attachment framework for CPTSD. Attachment theory is a commonly used framework 

for trauma in general and for interpersonal trauma specifically (Pearlman & Courtois 2005). 

Atkinson (1997) maintained that Attachment Theory is the theory of trauma due to the internal 

working model of oneself and others based on attachment and trauma experiences.  

From an evolutionary and developmental perspective, attachment theory is founded on 

the principal that bonding with others is “the most intrinsic essential survival strategy for human 

beings” (Johnson, 2019, p. 6). Empirical evidence provides ample support for this theory, 

replicating the findings over and over that span across human development, from cradle to grave 

(Bowlby, 1988), social support and connection in close relationships are essential to survival and 

produce positive mental and physical health outcomes (Nelson & Wampler, 2002). Conversely, 

fractures in interpersonal, social, and intrapsychic attachment systems pose a great risk for 

individual outcomes (Özcan et al., 2016). Furthermore, the encoded sense of threat for those with 

20 

 
 
 
CPTSD and cumulative attachment-based traumas are activated in the context of close 

relationships.  

Individuals develop a secure attachment when they experience attachment figures as 

reliably accessible, responsive, and emotionally attuned to their needs. A secure attachment 

enables individuals to experience “emotional balance,” which promotes the “development of a 

grounded, positive, and integrated sense of self and the ability to organize inner experience into a 

congruent whole” (Johnson, 2019, p. 7). Conversely, insecure attachment styles develop when 

attachment figures, for one reason or another, are not reliably accessible, responsive, and attuned. 

A mismatch of attunement can create a sense of neglect, rejection, abuse, and betrayal known as 

“attachment wounds” (Johnson, 2003). Some negative experiences are inevitable in human 

relationships; however, the accumulation of many and/or severe attachment wounds leads to an 

experience of instability and distrust in close relationships, resulting in an insecure attachment 

style.  

Attachment theory maintains that how an individual perceives attachment wounds 

manifests into the type of attachment style they develop (Bowlby, 1988). For example, anxious 

attachment occurs when an individual perceives a pattern of abandonment or betrayal from an 

attachment figure, either emotionally or physically. This attachment style manifests for 

individuals as an internal working model of how close relationships operate (Bretherton & 

Munholland, 1999), with an ever-present fear of losing attachment figures or losing trust and 

security with attachment figures. Similarly, avoidant attachment develops from the intrapsychic 

and interactional experience of one’s needs or emotions being dismissed by attachment figures, 

resulting in an avoidance of vulnerability in close relationships. Finally, disorganized attachment 

is rooted in the pervasive pattern of experiencing both forms of attachment wounds. 

21 

 
 
 
Disorganized attachment is exhibited by individuals who anxiously seek proximity while also 

maintaining emotional distance and distrust of others. Due to the accumulation and severity of 

attachment wounds at the root of disorganized attachment, some researchers prefer the term 

traumatic attachment over disorganized attachment to better describe the origin and presentation 

of this attachment style (Matheson & Weightman, 2020, p. 333). This connection is relevant 

given the CPTSD diagnosis, which also defines similar sequela based on related traumatic 

attachment experiences. 

It is important to acknowledge that each insecure attachment style is underscored by a 

fear-based response due to the internal working model of what to expect from close 

relationships; constantly managing the fear and belief that what happened before will happen 

again. The ongoing presence of fear in close relationships results in difficulties in emotion 

regulation evidenced by hyper- or hypo-arousal and persistent patterns of relational distress in 

existing and future relationships (Karatzias et al., 2018a).  

Adult attachment. The growing body of research on adult attachment illustrates the 

process of how attachment style serves as a “script” for future relationships (Atkinson, 1997; 

Hazan & Shaver, 1987; Nivison et al., 2022). As children grow into adults, their primary 

attachment figures and needs shift from parents and caregivers to intimate partners and close 

others with whom they can enjoy reciprocal and emotionally connected relationships (Aloni et 

al., 2020; Bretherton & Munholland, 1999; Hazan & Shaver, 1987). Based on attachment scripts, 

adults who developed a given attachment style in childhood are likely to attach the same way to 

intimate partners in adulthood (i.e., secure, anxious, avoidant, or disorganized) (Nivison et al., 

2022). Attachment style is also impacted by relationships in adulthood, and individual 

attachment styles are not necessarily fixed (Cassidy & Mohr, 2001; Makinen & Johnson, 2006). 

22 

 
 
 
Attachment can evolve and become either more secure or insecure depending on the 

characteristics and quality of ongoing experiences in close relationships. Despite the relative 

flexibility of attachment, it is also well understood that the more engrained an attachment style, 

the harder it can be to change (Hazan & Shaver, 1987; Nasim & Nadan, 2013). Attachment 

styles and relational scripts are powerful in dictating what individuals are accustomed to in close 

relationships, including what they will accept and expect in terms of ongoing proximity, 

accessibility, and emotional attunement from intimate partners (Cassidy & Mohr, 2001). 

Changes in attachment. Theorists and clinicians believe that individuals with past 

experiences of accumulated interpersonal trauma and severe fractures in attachment can shift 

toward secure attachment and a felt sense of safety in relationships (Smith & Stover, 2016; 

Volgin & Bates, 2016). Change in attachment style is based on accumulated experiences of 

security with current attachment figures that portray a felt sense of accessibility, attunement, and 

safety. As outlined by polyvagal theory (Porges, 2009) and supported by neurobiological studies 

on trauma populations, it can be difficult for those with a trauma history in relationships to 

experience emotional connection, even amidst a safe relationship due to physical changes in the 

brain that alter an individual’s ability to appraise for safety (Baldwin, 2013; Gerg, 2020; Lanius 

et al., 2010). Therefore, it is imperative that clinical interventions for these populations target 

relational and attachment processes in a way that emphasizes safety and establishes a secure base 

for clients (Chouliara & Narang, 2017; Liotti, 2004). Studies on adults with interpersonal trauma 

relay the importance of attachment-based interventions due to the high rates at which insecure 

attachment transmits to children and how difficult it is to develop a secure attachment without 

intervention (Aloni et al., 2020; Cassidy & Mohr, 2001). In this sense, interventions that can 

23 

 
 
 
effectively harness attachment mechanisms may serve as a key intervention point to support 

lasting outcomes for clinical populations.  

For many with PTSD, traumatic stimuli can include cars, highways, loud noises, or 

enclosed spaces. However, for those with CPTSD, such stimuli typically include an array of 

characteristics found in close relationships. These processes can make it difficult for CPTSD 

populations to adequately discern how to navigate intimate relationships, which is especially 

important given the reciprocal nature of how close relationships impact mental health (Baucom 

et al., 2012; Courtois & Ford, 2012). This pattern is also clinically challenging because CPTSD 

populations struggle “to understand when they are actually safe” (Gerge, 2020, p. 3), and they 

face difficulties establishing safe emotional boundaries and lasting security in their most intimate 

relationships. Existing literature emphasizes that CPTSD serves as an ongoing barrier to 

protective mechanisms of human connection (Barawi et al., 2020), and it stresses that future 

intervention research must address DSO-specific symptomology of disturbances in relationships 

and explore the integration of family and attachment-based therapies (Blow et al., 2020; 

Courtois, & Ford 2012; Fyvie et al., 2019; Stadtmann et al., 2017; 2018). 

Intervention 

Current state of intervention. The current standard of CPTSD intervention relies on 

three pillars of treatment: (1) clinical experience and expertise from mental health professionals, 

(2) current evidence-based PTSD interventions, and (3) exploratory treatments that have been 

tested for CPTSD-related symptomology and/or related populations (Karatzias et al., 2019). The 

operational diagnosis for CPTSD, along with the International Trauma Questionnaire (ITQ) 

measurement tool, are new to the mental health field, and therefore, solid empirical support for 

effective CPTSD treatment is scarce (Cloitre et al., 2018). Current research for CPTSD 

24 

 
 
 
intervention is in an exploratory phase, but there is growing evidence that highlights the promise 

of integrating social support and phase-based treatments that can address not only PTSD 

symptomology but also more intrusive and degenerative DSO symptomology (Cloitre et al., 

2020; Courtois & Ford, 2011; Karatzias et al., 2018a; Melton et al., 2020). 

Empirical evidence in CPTSD treatment. Traditional trauma interventions rely most 

heavily on exposure-based or trauma-informed cognitive behavioral interventions intended to 

treat the three clusters of PTSD symptomology (De Jongh et al., 2016; Karatzias et al., 2019). 

Specifically, an evidence-based trauma exposure therapy, Eye Movement Desensitization and 

Reprocessing (EMDR) Therapy, and forms of Cognitive Behavioral Therapy (CBT) are common 

treatments for traumatic stress response. These traditional interventions for traumatic stress are 

not as effective for CPTSD-specific DSO symptomology and leave many without effective or 

lasting care (Dorsey et al., 2016; Matheson & Weightman, 2020).  

Melton et al. (2020) conducted a rigorous mixed-methods meta-analysis that included a 

quantitative review of 104 studies, primarily randomized control trials, measuring the 

effectiveness of interventions for CPTSD-related symptomology across interpersonal trauma 

subgroups. Existing interventions that met the inclusion criteria for the study were either 

individual or group-based trauma-informed cognitive behavioral therapies, exposure therapies, 

and pharmacological and somatic interventions for CPTSD sequalae and trauma types (e.g., 

childhood sexual abuse, domestic violence, refugee status, and veterans). Compared with control 

groups across studies, evidence-based trauma therapies were effective in lowering PTSD-specific 

symptoms; however, they were less effective for more severely traumatized subgroups, 

especially veterans, and they were not effective in treating DSO symptomology. Authors also 

detailed concerns related to the lack of evidence on the long-term effectiveness of these 

25 

 
 
 
treatments, the presence of bias in a large portion of the studies, and the exclusion of diverse 

presentations of comorbidities in the studies (Melton et al., 2020). 

In addition to effectiveness, the acceptability of proposed interventions from CPTSD 

populations is another key issue that is largely unknown at this time due to the dearth of studies 

that address this question. Melton et al. (2020) concluded that based on their meta-analysis, 

exposure and group-based therapies were deemed acceptable to this population. This finding was 

based on lower client dropout rates for those forms of therapy, which show initial promise for 

these types of interventions for CPTSD; however, further information is needed and should 

include perspectives from the population itself to identify how and why they benefited from 

these therapies.  

These gaps are especially concerning due to three critical issues. First, there is a high 

prevalence of comorbidities in CPTSD populations (Hyland et al., 2017a; 2018b). Second, these 

analyses quantified a known and overarching issue in CPTSD intervention, which is that there 

are limited evidence-based treatments that effectively lower DSO symptoms (Karatzias et al., 

2019). Finally, the meta-analysis revealed that effective interventions for treating PTSD-specific 

symptomology do not adequately measure long-term effects (Melton et al., 2020). Based on their 

analysis, Melton et al. (2020) argue that future directions of research must work to identify 

“candidate psychological” treatments for the CPTSD populations (p. xxix). Preliminary studies 

have made similar arguments and recommend future research should incorporate known 

mechanisms of change in trauma therapy with promising approaches that can target the 

interpersonal nature of underlying DSO symptomology, including integrating close 

social/familial supports into therapy (Stadtmann et al., 2017; 2018)  

26 

 
 
 
CPTSD population perspectives. In addition to clinical and empirical 

recommendations, CPTSD survivors’ perspectives are viewed as a necessary ingredient to 

develop effective and acceptable interventions for this population; however, very few researchers 

have studied this topic by obtaining the voices of this group directly (Chouliara et al., 2020; 

Stadtmann et al., 2017). Some related studies have addressed interpersonal trauma survivors’ 

perspectives of therapy prior to the current diagnostic criteria from the ICD-11 (Chouliara et al., 

2012; Van der Linde & Edwards, 2013), and more recently, a few preliminary studies have 

started to scratch the surface and explore various perspectives of small samples of individuals 

with CPTSD (Chouliara et al., 2020; Matheson & Weightman, 2020; Stadtmann et al., 2018).  

A study by Chouliara et al. (2012) specifically reviewed adult survivors of child sexual 

assault (CSA) and sought their perspectives on clinical services in a thematic synthesis of 

existing literature across nine studies. The analysis explored survivors’ positive and negative 

experiences of psychotherapy and counseling treatment, along with their experience of disclosing 

their trauma in therapy and their perception of the effectiveness of treatment overall. Out of the 

nine studies reviewed, the methodological quality was deemed poor to moderate, which the 

authors recognized could have influenced the results of some studies leaning toward the 

possibility of positive researcher bias. The thematic synthesis did, however, reveal both positive 

and negative experiences of therapy on behalf of the population that provided helpful 

information for clinical care for survivors of CSA. For example, an important finding noted that 

CSA survivors attributed positive experiences in therapy and lasting clinical change to the 

quality of safety they felt within the therapeutic setting, including factors such as respect, equal 

power, participation, and flexibility. Therapist attunement and ability to address mistakes and 

misappraisals in therapy were also important. Furthermore, a notable positive factor was 

27 

 
 
 
therapist competence in addressing interpersonal abuse and trauma, especially with regard to 

attunement and pacing with the client’s emotional needs (Chouliara et al., 2012). In this sense, 

collaborative care with the client played a key role in a client’s sense of safety with the therapist 

and resulted in positive perceptions of therapy and therapeutic change. These findings are 

consistent with other studies, such as one conducted by Melton et al. that noted, “phased 

treatments that first start with helping people to feel safe before focusing on trauma symptoms 

might be beneficial for both post-traumatic stress disorder and additional psychological 

symptoms” (Melton et al., 2020, p. xxvii).  

Conversely, negative experiences in therapy resulted from imbalances in power and 

control and a therapist’s inability to adequately diagnose and treat interpersonal trauma, which 

led to distrust and the mishandling of clinical care for this already vulnerable population 

(Chouliara et al., 2012). One of the underlying themes from this synthesis addressed the felt 

tension between a medical model and social models of psychotherapy care. Survivors felt power 

and control issues were more prevalent in the medical model and did not respond well to the 

focus on pharmacological solutions, seeming to prefer a social model of treatment. From this 

analysis, Chouliara et al. (2012) determined that across studies, the negative themes were not 

investigated as systematically as the positive themes, which leaves room for a more in-depth 

understanding of negative experiences in clinical care for survivors of CSA and interpersonal 

trauma. 

Mechanisms of change in CPTSD interventions. Despite a lack of empirical evidence 

recognizing specific interventions for CPTSD, the large body of traumatic stress literature has 

synthesized some of the underlying processes in effective treatment for traumatic stress related to 

accumulated interpersonal trauma types (Fyvie et al., 2019; Karatzias et al., 2018a). Across 

28 

 
 
 
studies, a foundational element in effective trauma intervention lies in the success of 

neurobiologically overriding a disturbing experience by connecting formerly traumatic stimuli to 

a new safe/neutral experience (Gerge, 2020; Karatzias et al., 2019; Mahoney et al., 2019; Melton 

et al., 2020). This process lessens the salience of traumatic memories that activate trauma 

response in the nervous system, and research notes that experiential therapies are useful in 

achieving this goal (Cloitre et al., 2011; De Jongh et al., 2016; Khalfa & Touzet, 2017). There is 

also an emphasis on the importance of shifting “attitudes and values” (Van Der Linde & 

Edwards, 2013, p. 28) of the interpersonally traumatized person from feeling chronically fearful, 

to establishing safety and confidence in their ability to establish close bonds with others (Dugal 

et al., 2020).  

Despite the perceived benefits of individual trauma intervention, trauma processing is 

also known to be extremely burdensome on clients with high rates of client drop out. In one case 

example, a CPTSD client described the process by saying, “it is like uprooting trees, taking them 

out with roots and all” (Van Der Linde & Edwards, 2013, p. 24). Studies on existing therapies 

reveal that current individual interventions for traumatic stress are not as effective and can pose 

severe harm, especially when individuals still live within a setting that chronically activates or 

triggers past trauma (Karatizias et al., 2019b). Therefore, the consensus from clinicians and 

empirical research relays the added difficulty in treating CPTSD due to the nature of traumatic 

stimuli as it is much less containable than circumscribed trauma and is generally interwoven into 

close human relationships (Stadtmann et al., 2017; 2018). An additional gap in treatment lies in 

the fact that dealing with complex interpersonal trauma is clinically challenging, and many 

therapists are underprepared to work from a systemic conceptualization either in individual or 

dyadic treatment (Kozlowska, 2020). Theoretical and empirical studies hypothesize that 

29 

 
 
 
interventions that integrate safety and positive social support can mediate this effect and 

therefore show great promise in the field of CPTSD intervention (Cloitre et al., 2011; Karatizias 

et al., 2019).  

Another recent qualitative analysis by Chouliara et al. (2020) explored the perceived 

mechanisms of change in group-based therapies for interpersonal trauma populations from the 

perspective of clients and therapists. This study expanded on the current knowledge as to why 

group-based interventions are often used for people with accumulated interpersonal trauma 

histories, noting the added stabilization effect of the social environment in therapy. Findings 

from this study suggest that a patient-centered relational framework is most acceptable and 

effective for interpersonal trauma and CPTSD populations. Specific findings from this study 

suggest that mechanisms of change for this population are related to a person-centered 

humanistic therapeutic framework that focuses on a present process rather than content. These 

findings are consistent with common factors that support change in therapy (Johansson & 

Høglend, 2007) but seem to be especially important for more vulnerable CPTSD populations 

(Herman, 1992; Mahoney et al., 2019). It is believed that the relational nature of group therapy 

not only stabilizes participants but also contributes to what Chouliara et al. (2020) refer to as a 

reorganization of self-concept, which is a core component of CPTSD treatment (Hyland et al., 

2017a). 

Based on current gaps in the literature, researchers have recommended that in-depth 

qualitative studies are needed to collect perspectives from both CPTSD persons and their 

families to better inform and tailor future intervention adaptations (Stadtmann et al., 2017; 2018). 

Some of this work has begun, and results from a recent qualitative study by Matheson and 

Weightman indicates that individuals with CPTSD believed that interventions should focus more 

30 

 
 
 
on relational safety and trust with close others, including the therapist but extending to others in 

the context of the client (2020). 

Expanding CPTSD treatment to relational interventions  

Systemic therapy. The field of systemic family therapy operates from an ecological 

perspective of care and regards family as the core system from which therapeutic interventions 

can effectively address the biopsychosocial components of mental health diagnoses (Baucom et 

al., 1998; 2012; 2014; Doss et al., 2022). Family systems theory maintains that individual 

psychopathology results from interpersonal interactional patterns that are dysfunctional and 

either directly influence individual disorders and/or allow unresolved issues to persist (Baucom 

et al., 2014). Therefore, systemic family therapy aims to treat the family system as the target of 

intervention rather than seeking to produce substantial and sustainable therapeutic outcomes at 

the individual level.  

The purpose of using relational interventions to treat individual diagnoses like CPTSD is 

twofold. First, the systemic approach is an acknowledgement that all individuals, and, therefore, 

individual dysfunctions, exist within a larger social/family system, and treatment that does not 

shift the status quo of the system will not be sustainable for the individual (Baucom, et al., 1998; 

2012; 2014; Doss et al., 2022). From this stance, individualized treatment is believed to place a 

great deal of burden on persons within a system to not only maintain intrapsychic gains made in 

therapy without adequate support but to also shift the status quo within their family system 

singlehandedly. Furthermore, the systemic conceptualization holds that individual symptoms, 

such as those found in traumatic stress, extend to the system (Nelson Goff & Smith, 2005). This 

is especially relevant with intimate partners in the context of traumatic stress exemplified by the 

CATS Model (Nelson Goff & Smith, 2005; Oseland et al., 2016), which outlines how individual 

31 

 
 
 
traumatic stress affects the system of the couple relationship. The CATS model defines how one 

partner’s individual factors, such as individual functioning and individual predisposing factors 

(trauma and resources), interact within the dyad to create the couple’s model of functioning, 

impacting attachment, satisfaction, roles, and conflict. In this way, the systemic approach to 

treatment “emphasizes the interdependence of individuals within a family system” (Baucom et 

al., 2014, p. 445). This idea extends beyond the ecological perspective that individuals are 

influenced by their particular system and details the way in which humans as a social species 

develop and change based on iterative and reciprocal interactions with those closest to them.  

Baucom et al. (2014) argued that despite the fact that individual therapy can be effective 

for certain individuals and certain diagnoses, there is a great deal of evidence suggesting that 

individual treatments are lacking. This study further suggests that relationally based therapies 

offer a missing component to the current standard of individualized mental health care. 

Longitudinal research supports this theory in that individual treatment can be hindered by 

relational issues. Furthermore, relational distress itself greatly enhances the likelihood of 

remission for disorders such as depression, anxiety, gambling, and PTSD both during and after 

treatment (Baucom et al., 2014; Lee, 2015). Therefore, the benefit of relational therapies that 

include an individual’s family system lies in the systemic approach, which not only accounts for 

preexisting relational distress but also actively works to support relational distress that can occur 

throughout therapy. An added benefit of systemic therapies is the way in which relational skills 

and bonds are deepened within the context of therapy, which is believed to support positive 

outcomes in individual diagnoses (Baucom et al., 2014; Doss et al., 2022; Johnson 2003; 2019).  

The second purpose of using relational interventions to treat individual diagnoses is to 

integrate family as a social support that is not only active in clinical change as a system but that 

32 

 
 
 
also acts as a buffer against the known burden of treatment (Baucom et al., 2014; Choularia et al, 

2012; Cloitre, 2015; Matheson, 2016). Relational models of therapy meaningfully integrate 

family members to address symptoms that impact the system as a whole, establishing a shared 

experience and supportive environment, which is key in traumatic stress intervention (Chouliara, 

2012). This is a stark shift from the medical model of care, which has been linked to client 

dropout, especially in CPTSD populations (Chouliara, 2012). Client dropout rates for CPTSD are 

also high in individual psychotherapy treatment, which some researchers attribute to a lack of 

proper “emotional support outside” of the therapeutic environment (Matheson 2016, p. 340). 

Researchers theorize that therapies that can effectively and meaningfully integrate family into 

treatment can greatly mediate against client burnout and thus lower drop out (Matheson & 

Weightman, 2020). Cloitre (2015) argued that one size does not fit all in traumatic stress 

intervention, which especially applies to the differentiation between treating circumscribed 

trauma and PTSD compared to accumulated interpersonal trauma and CPTSD. Across studies, 

researchers maintain that the mental health field should not be satisfied with the status quo of 

traumatic stress intervention for CPTSD, which relies on non-relational medical models of care 

(Karatzias et al., 2019a) 

Emotionally focused couple therapy as a candidate CPTSD treatment. The current 

interventions recommended for CPTSD focus on establishing safety in therapy and close 

relationships, attachment-based and relational interventions, and traumatic memory reprocessing 

(Matheson & Weightman, 2020; Mahoney et al., 2019). EFT, an attachment-based couple 

intervention (Johnson, 2003; 2019), shows promise in treating the underlying interpersonal 

components of this complex disorder (MacIntosh, 2018; Roundy, 2017). Prior research has 

argued that EFT is “ideally suited” (Blow et al., 2015, p. 261) for treating traumatic stress 

33 

 
 
 
symptomology and relational disturbances for couples who face trauma (Greenman & Johnson, 

2012; McRae et al., 2014; Wiebe & Johnson, 2016). Furthermore, EFT has exhibited success in 

treating interpersonal trauma populations with related trauma types and sequela to CPTSD, 

including adult survivors of childhood sexual abuse (Dalton et al., 2013) and veterans 

(Weissman et al., 2017). 

EFT is a leading evidence-based couples intervention founded on the principles of adult 

attachment-theory and a humanistic philosophical stance, which emphasizes present process in 

therapy (Johnson, 2003; 2019). The relational setting via the inclusion of intimate partners and 

attachment framework, along with the emphasis on present process and a humanistic stance, are 

all proposed to be necessary components for effective CPTSD interventions that are also 

acceptable to this population (Chouliara et al., 2020). Furthermore, a primary takeaway from the 

existing traumatic stress intervention literature for CPTSD is the necessity of establishing safety 

within the therapeutic environment (Karatzias et al., 2019a; Stadtmann et al., 2018; Van der 

Linde & Edwards, 2013), which is a core component of the EFT intervention that begins in the 

de-escalation stage of the model (Welch et al., 2019). Establishing emotional safety between 

partners and within the therapeutic relationship is central in EFT, occurring through therapist 

attunement with clients and then expanding to partners throughout the three phases of treatment 

(Welch et al., 2019).  

The literature continues to address the mechanisms of change in adult attachment targeted 

by EFT that can be effective for interpersonal trauma populations (Blow et al., 2015; Dalton et 

al., 2019; Johnson 2005; MacIntosh & Johnson, 2008). Roundy (2017) has provided a 

comprehensive comparison of EFT’s three treatment phases to the recommended three stages of 

phase-based relational treatments proposed for effective CPTSD intervention (Cloitre et al., 

34 

 
 
 
2011; Courtois & Ford, 2012). Specifically, the EFT model consists of three phases which seek 

to: (1) deescalate and alter the negative interactional cycle between partners, (2) repair 

attachment wounds and rewrite attachment scripts though corrective enactments between 

partners, and (3) consolidate and integrate a restored internal working model of relationships by 

establishing a secure base between partners (Johnson, 2019; Roundy, 2017). Over the course of 

treatment, EFT aims to treat negative interpersonal cycles and negative beliefs of self and others 

in the context of close relationships, and it establishes secure bonds through experiential 

enactments (Johnson 2019).  

A secure intimate partner relationship is a strong moderator against negative outcomes 

for CPTSD populations (Vaillancourt-Morel et al., 2019; Volgin & Bates, 2016). Therefore, EFT 

is a compelling candidate intervention for CPTSD because it seeks to target and repair the 

attachment system by first establishing genuine interpersonal safety and it then leverages the 

intimate partner relationship as an active ingredient for rewriting emotional experiences via 

emotional enactments between partners (Johnson, 2002; 2019). These components are key for 

treating DSO symptomology (Matheson & Weightman (2020) and are known to be effective for 

PTSD symptoms (Blow et al., 2020; MacIntosh & Johnson, 2008; Paivio & Niewenhuis, 2001), 

which has been difficult to capture in a single intervention.  

35 

 
 
 
 
 
CHAPTER 3: METHODOLOGY  

Research Design 

The research questions for this study will guide the search for a deeper understanding of 

how couples experience the impact of CPTSD on their intimate relationships. In addition, they 

will guide the exploration of client perspectives about the acceptability of EFT for partners with 

accumulated interpersonal trauma histories. To achieve this aim, I used qualitative methods and 

employed framework analysis, a subtype of thematic analysis, to uncover salient and in-depth 

descriptions from couples within the context of the CPTSD diagnosis and EFT treatment. To 

answer the research questions of this study, qualitative data were generated from semi-structured 

interviews with 10 couples who were currently participating in EFT. At least one partner in each 

couple met the diagnostic criteria for CPTSD at the time of the interview.  

Theoretical Framework  

The proposed study used a phenomenological approach and use a constructivist paradigm 

to examine responses to research questions (Leavy, 2022). Framework analysis, as outlined by 

Gale et al. (2013) and Parkinson et al. (2016), was used to analyze themes under each branch of 

inquiry. The phenomenological orientation in qualitative research seeks to uncover how a given 

population experiences the phenomena under investigation (Leavy, 2017). This approach centers 

participants’ perspectives and language around a specific topic, which can then inform future 

directions for research, theory, and treatment adaptations. Qualitative interview methods are 

considered a gold standard in exploring emergent themes and uncovering the lived experiences 

from participants in phenomenological studies (Creswell & Poth, 2018; Leavy, 2022). Therefore, 

a phenomenological design was ideal for achieving the goals of this study to gain rich and in-

depth descriptions from couples who experience CPTSD symptomology in their relationships 

36 

 
 
 
and to examine if, how, and in what ways they believed EFT treatment is effective in light of 

their personal histories of accumulated interpersonal trauma.  

The constructivist paradigm maintains that knowledge is constructed though the iteration 

and interaction of individuals, and it explicitly acknowledges the co-construction of meaning that 

occurs using phenomenological methodology (Creswell & Poth, 2018; Leavy, 2022). In this 

sense, the phenomenological methodology helped to make sense of the meaning constructed by 

and between the couple. The constructivist orientation also recognizes the researcher as a co-

constructor of findings in qualitative research in that the researcher plays a role in the analysis of 

data and brings their biases to this process. In this study, empirical findings were co-constructed 

through iterative interactions with study participants, EFT therapists during treatment and 

recruitment, myself as the interviewer/researcher, and the research guidance committee. 

As a form of thematic analysis, framework analysis details a systematic process in 

qualitative methodology that determines thematic categories by integrating a priori concerns 

from theoretical and empirical literature in combination with “emergent issues” from the present 

study (Parkinson et al., 2016, p. 116). For this reason, framework analysis is useful when 

research questions, like those in the present study, seek to address distinct goals that are 

“contextual” and “evaluative” (i.e., capturing the lived experience of couples in the context of 

CPTSD, and evaluate client perspectives of an intervention for a specific psychological concern 

(Parkinson et al., 2016, p. 113). 

Methodological Rationale 

Researchers collectively recognize the clinical utility afforded by the new 

conceptualization and measurement of CPTSD and highlight the necessity of qualitative analysis 

that involves CPTSD populations at this current juncture in treatment development (Cloitre et al., 

37 

 
 
 
2020a; 2020b). Working with traumatic stress “in the context of the couples’ relationship is 

highly promising”; however, due to the vulnerability of the population, the expansion of 

relational interventions for traumatic stress “should not occur in a haphazard manner, but rather 

with caution and an abundance of planning” (Blow et al., 2020, p. 241). It is in this attitude that I 

approached this study, prioritizing the lived experiences, perspectives, and opinions of 

individuals living with CPTSD and their partners to detail how the disorder impacts their 

relationships and how they experience the EFT intervention. 

The stage of clinical research this study proposes is what Onkin et al. (2014) view as 

Stage 0 in clinical intervention research. This stage is key in intervention development and asks 

basic questions to help understand mechanisms of change along with the mediators or the 

moderator of the intervention. Stage 0 can occur at any point within intervention development if 

there is key information needed to support the further development of effective interventions for 

a specific goal. A goal of the current study was to add to the existing literature and “facilitate the 

creation of ever more potent and implementable interventions” (Onkin et al., 2014, p. 28)—in 

this case, using an attachment-based couple intervention, EFT, for CPTSD. Based on the 

research questions, this study seeks to identify if certain aspects of EFT are especially important 

for CPTSD populations as facilitators of barriers to engagement in treatment and clinical change. 

Additionally, this research sought to explore if and how the intervention should be adapted to 

address heightened emotion regulation difficulties or disassociation that is typical for CPTSD.  

Sampling 

 The consensus from the qualitative methodological literature for phenomenological 

studies maintains that 8 to 20 total participants in a specific sample with shared characteristics 

will enable a phenomenological study to reach data saturation (Creswell & Poth, 2018; Francis et 

38 

 
 
 
al., 2010; Monson et al.,  2020; Stadtmann et al, 2017). Therefore, the sample for this study 

included 10 couples (20 individuals) who were currently active in EFT treatment, where at least 

one partner met the diagnostic criteria for CPTSD and has a history of interpersonal trauma. This 

study used purposive, convenience, and snowball sampling by recruiting participants from 

experienced EFT therapists within the researcher’s professional clinical networks who work with 

couples that have accumulated interpersonal trauma histories and ongoing CPTSD 

symptomology (Leavy, 2017). The goal of purposeful sampling is to collect data from 

information-rich cases. In this case, EFT therapists were the first point of contact for the study 

and helped direct participants to the study. 

Intervention  

EFT is a three-phase treatment that includes de-escalation, partner softening and 

reengagement, and consolidation (Johnson, 2003; 2019). To capture the most salient responses of 

participants’ experiences of EFT treatment, I interviewed participants who had been in EFT 

therapy for at least eight weeks to ensure they were adequately exposed to the core components 

of EFT and/or are well into or past stage one of the EFT treatment model. 

Interventionists and fidelity. I recruited therapists who were either certified in EFT or 

actively gaining certification and thus receiving ongoing EFT supervision by an EFT trainer. To 

obtain certification in EFT, therapists must either be a master’s level licensed mental health 

professional or under the supervision of a licensed mental health professional in either marriage 

and family therapy, social work, or licensed professional counseling. 

39 

 
 
 
 
 
 
Procedures 

Recruitment. Community engaged recruitment. Prior to conducting this study, all 

procedures were approved by the Michigan State University Internal Review Board. Recruitment 

for the current study took place in two ongoing stages across the open recruitment period of 

November 2021 to June 2022. The first stage involved a community-engaged approach, during 

which I actively recruited advanced EFT therapists as recruitment “liaisons” and “gatekeepers” 

to clinical participant couples for the study (Archibald & Munce, 2015, p. 35). A key component 

of a community-engaged recruitment methodology highlights characteristics of the study 

recruiter, which are central to successful recruitment (Archibald & Munce, 2015).  

As an EFT therapist and researcher, I embedded myself in each of EFT training networks 

beginning in 2019, several years prior to the study. Researcher embeddedness within the EFT 

therapist community was a key component to the recruitment of this study to build rapport with 

therapists who in turn shared the study information with their clients. In addition to advanced 

training within these EFT networks, the majority of the therapist networks over the past several 

years of my involvement have included consultation around implementing EFT with couple 

populations that report interpersonal trauma histories and struggles with resulting trauma 

symptoms within the context of their relationship. This knowledge supported the feasibility of 

recruitment for a population that would be otherwise difficult to access.  

Stage one. The first stage of recruitment for this study involved actively recruiting EFT 

therapists to participate as liaisons in the study by sharing the study information with broader 

EFT networks and individuals. Interested EFT therapists were asked to take an EFT therapist 

eligibility survey using Qualtrics survey software, which briefly screened to determine their level 

of training and fidelity to the EFT model in working with couple clients. Eligible therapist 

40 

 
 
 
liaisons reported to completing at a minimum of core skills 2 with active ongoing EFT 

supervision up through certification and reported that they used EFT core components with 

couple clients. Participating recruitment therapists had completed advanced EFT training, with 

24 who had completed core skills 4 and five who completed certification in EFT. 

After the screening, eligible therapists were offered additional information about the aim, 

scope, and structure of the study, along with study recruitment materials, including the study 

flyer (Appendix A) and a link to the couple screening Qualtrics survey. Studies that involve 

gatekeepers benefit when those involved “have a thorough understanding of the study purpose 

and eligibility criteria” (Archibald & Munce, 2015, p. 35). Therefore, as the study organizer, I 

worked closely with therapists and offered online informational meetings to help better inform 

therapist liaisons about the study’s recruitment process, which greatly supported effective 

recruitment.  

Stage two. The second stage of recruitment took place after establishing EFT therapists as 

participating liaisons for the study on a rolling basis between November 2021 and May 2022. 

Participating therapists emailed study information (study flyer, Appendix A) to their couple 

clients and/or posted a printed flyer in their offices. Therapists were asked to clarify that the 

study was not required, and it was completely separate from their therapeutic environment. The 

recruitment materials directed clients to the study website, which included more detailed 

information about the study format, which entailed a joint Zoom interview with couples and a 

link to the client screening survey. Recruitment for this study took place over an eight-month 

period and ended once the study reached 10 couples and qualitative data indicated saturation. 

Screening and eligibility. Screening for this study included multiple layers, which first 

involved screening for therapist eligibility when unknown and then screening for client couple 

41 

 
 
 
eligibility. The couple client screening involved five key considerations based on eligibility: (1) 

couples had to be in a committed relationship of at least six months, and each above 18 years of 

age, (2) participating couples had to be active in EFT treatment with an eligible EFT therapist 

over the course of at least eight weeks prior to participating in the study to sufficiently speak to 

their experience of EFT, (3) participants had to pair with their partner, who also filled out the 

screening survey as indicated by matching names provided (their own and their partner’s), emails 

(their own and their partner’s), location, EFT therapist, and duration of treatment, (4) one or both 

partners had to meet the criteria for CPTSD as per the ITQ, and (5) both partners had to indicate 

that they wanted to participate in the joint interview. At the end of the recruitment period, a total 

of 33 individuals completed the initial screening survey. Once participants passed the first 

screening, they were sent a second survey that asked for demographic information and a final 

confirmation allowing me to jointly email the couple to send their informed consent forms and 

schedule the two-hour interview. A total of 24 individuals completed the second screening 

survey. When couples did not meet all of the above criteria based on the online screening 

protocol, they were excluded from the study.  

Measures. 

Demographics. The demographic screening (see Appendix D) was standard and asked 

participants general questions regarding their age, gender, race and ethnicity, level of education, 

SES, relationship status, length of time in their current relationship, number of children, and their 

length of time in EFT. The demographic results are summarized in Table 1.  

International Trauma Questionnaire. The ITQ (Appendix F) was developed for the ICD-

11 as the only reliable and valid measure that differentiates between PTSD and CPTSD as 

distinct disorders (Cloitre et al., 2018). The ITQ consists of 18 Likert style questions that assess 

42 

 
 
 
for both PTSD and CPTSD as distinct diagnoses. The ITQ factor structures have been 

independently validated to support the measure’s accuracy in diagnosing likely CPTSD and 

PTSD across populations (Cloitre et al., 2018; Tay et al., 2018). The ITQ has also been validated 

across the globe with diverse populations ranging between age groups, geographic locations, and 

trauma types (Fernández-Fillol et al., 2020; Haselgruber et al. 2019). The ITQ is appropriate for 

the study population as the only current and valid measure that can assess for CPTSD. The ITQ 

was administered as part of the initial online Qualtrics screening survey. If at least one member 

of the couple did not meet the clinical cutoff for CPTSD, they were excluded from the study. The 

clinical cutoff for CPTSD class membership is sixteen out of a possible seventy-two. The ITQ is 

scored by individual scores equal or greater than two. A moderate score for each PTSD symptom 

(avoidance, hypervigilance, and reexperiencing) and DSO symptom (emotion regulation 

difficulties, negative self-concept, and disturbances in relationships), along with moderate levels 

of functional impairment for each were required for a CPTSD diagnosis.  

Enrollment. Once participants met study inclusion criteria based on the screening 

materials, they were offered the informed consent for the study (Appendix B). After participants 

had filled out the informed consent, they were considered enrolled in the study.  

Sample. Resulting from the screening process, 12 couples (24 participants) met the 

inclusion criteria for the study; however, two couples opted out of participating in the joint 

interview due to scheduling constraints. Therefore, the total sample included ten couples (20 

participants). The final sample included (n=19) participants meeting the full criteria for a CPTSD 

diagnosis as per the ITQ and one participant who indicated trauma symptomology, but did not 

meet the cut off for PTSD or CPTSD. Interestingly, this led to a sample of predominately dual 

43 

 
 
 
trauma couples for this study. Participant scores indicating PTSD, DSO, and total scores for each 

participant are summarized in Table 2. 

Participant demographics. A final count of 10 couples, or 20 individuals, participated 

in this study (Table 1), including 40% males (n=8) and 60% females (n=12). The participants 

indicated ages between 25 and 65+ years old. A majority of participants (80%) were married 

(n=16), while the remaining 10% were in a dating relationship (n=2), and 10% were in a dating 

relationship after their divorce (n=2). The average relationship length was 17 years, ranging from 

3 to 42 years. A majority of participants (95%) had children within the span of their relationship. 

A majority of participants (80%) identified as White/Caucasian (n=18), whereas 10% identified 

as Hispanic or Latino (n=2). Participants’ sexual orientation varied, with 75% identifying as 

heterosexual (n=15), 10% identifying as queer (n=2), 5% identifying as lesbian, (n=1), 5% 

identifying as bisexual (n=1), and 5% identifying as pansexual (n=1). All participants lived 

within the United States, with 50% in the Northeast (n=10), 20% in the Southwest (n=4), 20% in 

the West (n=4), and 10% in the Midwest (n=2). This sample overall experienced high SES, with 

the majority of participants (65%) reporting a gross income of $100,000 or higher (n=13), 20% 

making $80,000–$99,000 (n=4), 10% making $60,000–$79,000 (n=2), and 5% making $40,000–

$59,000 (n=1). Participants’ education also varied, with 5% having earned a doctorate degree 

(n=1), 45% completing a graduate or master’s degree (n=9), 40% with a bachelor’s degree (n=8), 

5% completing some college (n=1), and 5% completing technical school (n=1). A majority of 

participants (75%) were employed full time (n=15), with 15% employed part-time (n=3), and 

10% retired (n=2).  

Almost the entire sample met the criteria for CPTSD (n=19) based on the scores from the 

self-report ITQ in their screening (Table 2), which indicated an average score of 38 (range=22–

44 

 
 
 
61). These score indicate that the sample overall scored moderate to high in terms of the severity 

of their CPTSD symptomology. Further, couple participants scored relatively close together at an 

average of 10 points apart (range= 2-22), which informs this study not only as dual trauma 

participant couple, but couples who share a similar level of CPTSD symptom severity.  

45 

 
 
 
 
Table 1   

Participant Demographics  

Participant 
couple 

Participant 
Pseudonym 

Gender  

Sexual 
Orientation  

Age 

Relationship 
Status 

Current 
Relationship 

EFT 
Sessions 

Children 

Employment 

Education 

Annual household 
income 

Ethnicity 

1 

2 

3 

4 

Erin 

Female 

Queer 

25-34  Married 

9 years 

25-51 

1 child 

Full-time 

Graduate/ Master’s 
Degree 

US$100,000 or 
higher 

White / 
Caucasian 

Amy 

Cis-Female   Queer 

25-34  Married 

9 years  

25-51 

1 child 

Full-time 

Doctorate Degree 

Sarah 

Female  

Heterosexual   35-44  Married 

23 years  

17-24 

1 child 

Full-time 

College Degree 

Evan 

Male 

Heterosexual   35-44  Married 

20 years 

17-24 

1 child 

Full-time 

Some college 

US$100,000 or 
higher 

White / 
Caucasian 

US$60,000 - 
US$79,000 

Hispanic 
or Latino 

US$60,000 - 
US$79,000 

Hispanic 
or Latino 

Erica 

Female 

Heterosexual 

45-54 

Adam 

Cis-Male 

Heterosexual 

45-54 

Monica 

Female 

Heterosexual 

45-54 

Brent 

Male  

Heterosexual 

45-54 

Divorced, In a 
committed 
relationship 

Separated, In 
a committed 
relationship 

Married, 
Divorced 

Married, 
Divorced 

3 years  

8-16 

2-3 children 

Full-time 

Graduate/ Master’s 
Degree 

US$100,000 or 
higher 

White / 
Caucasian 

3 Years 

8-16 

None 

Part-time 

College Degree 

US$40,000 - 
US$59,000 

White / 
Caucasian 

7 years 

8-16 

4-5 children 

Full-time 

College Degree 

US$100,000 or 
higher 

White / 
Caucasian 

6 years 

8-16 

2-3 children 

Full-time 

Graduate/ Master’s 
Degree 

US$100,000 or 
higher 

White / 
Caucasian 

46 

 
 
 
 
 
Table 1 (cont’d) 

5 

6 

7 

8 

Kirsten 

Female 

Heterosexual 

35-44  Married 

16 years  

17-24 

2-3 children 

Unemployed/ 
retired 

Graduate/ Master’s 
Degree 

US$100,000 or 
higher 

White / 
Caucasian 

Mitchell  

Male 

Hetero 
sexual  

45-54 

Married, 
Widowed 

17 years  

17-24 

2-3 children 

Full-time 

Graduate/ Master’s 
Degree 

US$100,000 or 
higher 

White / 
Caucasian 

Brittney 

Female 

Heterosexual 

35-44  Married 

12 years 

17-24 

2-3 children 

Part-time 

College Degree 

12 years 

17-24 

2-3 children 

Full-time 

Technical school 

US$100,000 or 
higher 

White / 
Caucasian 

US$80,000 - 
US$99,000 

White / 
Caucasian 

Ryan 

Male 

Heterosexual 

35-44 

Matthew 

Male 

Heterosexual 

55-64 

Annette 

Female 

Heterosexual 

45-54 

Married, 
Divorced 

Divorced, in a 
committed 
relationship  

Divorced, in a 
committed 
relationship  

22+ years 

8-16 

2-3 children 

Full-time 

College Degree 

US$80,000 - 
US$99,000 

White / 
Caucasian 

22 years 

8-16 

2-3 children 

Full-time 

College Degree 

US$100,000 or 
higher 

White / 
Caucasian 

John 

Male 

Heterosexual 

65+ 

Married 

46 years 

52 or 
more 

2-3 children 

Unemployed/ 
retired 

Graduate/ Master’s 
Degree 

US$100,000 or 
higher 

White / 
Caucasian 

Gina 

Female 

heterosexual 

65+ 

Married 

46 years 

52 or 
more 

2-3 children 

Part-time 

Graduate/ Master’s 
Degree 

US$100,000 or 
higher 

White / 
Caucasian 

47 

 
 
 
 
 
 
Table 1 (cont’d) 

Cathy 

Gender 
Fluid 

Lesbian 

45-54 

Married, 
Divorced 

20 years 

Janet 

Female 

Pansexual 

55-64  Married 

20 years 

52 or 
more 

52 or 
more 

2-3 children 

Full-time 

Graduate/ Master’s 
Degree 

US$100,000 or 
higher 

White / 
Caucasian 

2-3 children 

Full-time 

College Degree 

US$100,000 or 
higher 

White / 
Caucasian 

Rachel 

Female 

Heterosexual 

45-54 

Married, 
Divorced 

11 years 

25-51 

1 child 

Full-time 

Graduate/ Master’s 
Degree 

US$80,000 - 
US$99,000 

White / 
Caucasian 

9 

10 

Harry 

Male 

Heterosexual 

45-54  Married 

10 years 

25-51 

1 child 

Full-time 

College Degree 

US$80,000 - 
US$99,000 

White / 
Caucasian 

48 

 
 
 
 
Table 2 

Participant ITQ Scores 

Participant 
Couple 

Participant 
pseudonym 

PTSD 
Score 

PTSD FI 

Meets 
PTSD 
Diagnostic 
Criteria 

DSO 
Score 

DSO FI 
Score 

Meets 
CPTSD 
Diagnostic 
Criteria 

Total 
Score 

1 

2 

3 

4 

5 

6 

7 

8 

Amy 
Erin 
Sarah 
Evan 
Adam 
Erica 
Monica 
Brent 
Kirsten 
Mitchell 
Brittney 
Ryan 
Annette 
Matthew 
Gina 
John 

19 
6 
7 
8 
6 
10 
9 
10 
13 
14 
11 
12 
19 
20 
15 
16 

5 
5 
10 
5 
3 
5 
7 
4 
6 
6 
5 
3 
11 
12 
3 
0 

5 
3 
11 
4 
4 
6 
10 
4 
9 
6 
3 
6 
10 
11 
2 
0 

Yes 
Yes 
Yes 
Yes 
Yes 
Yes 
Yes 
Yes 
Yes 
Yes 
Yes 
Yes 
Yes 
Yes 
Yes 
No 

40 
22 
42 
31 
31 
29 
47 
25 
49 
37 
31 
39 
61 
50 
28 
24 

11 
8 
14 
14 
18 
8 
21 
7 
21 
11 
12 
18 
21 
7 
8 
8 

Yes 
Yes 
Yes 
Yes 
Yes 
Yes 
Yes 
Yes 
Yes 
Yes 
Yes 
Yes 
Yes 
Yes 
Yes 
No 

49 

 
 
 
 
 
Table 2 (cont’d) 

9 

10 

Cathy 
Janet 
Rachel 

Harry 

17 
18 
21 

22 

7 
6 
7 

4 

Yes 
Yes 
Yes 

Yes 

14 
8 
18 

11 

7 
6 
7 

5 

Yes 
Yes 
Yes 

Yes 

45 
38 
53 

42 

Notes: The PTSD diagnoses is designated by a minimum PTSD score greater than or equal to six (maximum 24) with a PTSD FI score greater or 
equal to two (maximum twelve). The CPTSD diagnoses is designated by meeting the full criteria for the PTSD diagnosis plus a minimum DSO 
score greater than or equal to six (maximum 24) with a DSO FI score greater or equal to two (maximum twelve) as per (Cloitre et al., 2018). 

50 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
The sufficiency of this sample size is supported by qualitative methodological literature 

for phenomenological studies that maintain that 8 to 20 total participants in a specific sample 

with shared characteristics can enable a study to reach data saturation (Creswell & Poth, 2018; 

Francis et al., 2010; Manson, 2010; Stadtmann et al, 2017). The sample for this study included 

10 couples who were currently active in EFT treatment where at least one partner met the 

diagnostic criteria for CPTSD and had a history of interpersonal trauma.  

Interview procedure. Qualifying participant couples were interviewed using a semi-

structured interview guide (Appendix G). Interviews, which took place online, were recorded 

using HIPPA-compliant Zoom meeting session software. Prior to starting the interview, as the 

researcher and interviewer for the study, I verbally reviewed the informed consent with 

participants, provided an overview of the study’s purpose and questions, reviewed risks and 

benefits of the study, and then informed participants that they may elect to skip any questions or 

end their participation in the study at any time. Once participants provided their final verbal 

consent for the study, the interviews commenced. 

Interview. The content of the interview (Appendix G) did not inquire about details 

regarding past trauma in the screening survey or otherwise but acknowledged participant 

histories of past accumulated trauma and ongoing CPTSD symptomology. In this way, the 

interview questions did not involve any discussion of past traumas but rather focused on current 

experiences of trauma symptomology within the relationship to address the first research 

question. Then, couples were asked questions regarding their experience of the EFT intervention, 

to reflect on their therapy progress and experience, and finally to discuss what they found to be 

both useful and difficult about the model, addressing the second research question. Interview 

51 

 
 
 
questions were asked of partners in an alternating fashion to give both partners the opportunity to 

respond first equally. 

Data collection. Qualitative interviews averaged two hours per participant couple and 

ranged between 78 and 134 minutes. My data collection, therefore, resulted in approximately 20 

hours of joint in-depth descriptions from participant couples regarding their experience of the 

ways in which each distinct CPTSD symptom impacts their relationship (chapter 4), and their 

experience of EFT in the context of those symptoms (chapter 5). Clinical couples were 

interviewed together to ensure complete and salient responses regarding their dyadic 

experiences, with equal time allotted to both partners. All interviews were voice recorded via 

Zoom video conferencing software. Recordings were also electronically encoded and double 

password protected. Interviews were transcribed verbatim and transferred to Word files that were 

stored under the same electronic protection standards as the audio files. 

Data Analysis. For the analysis of this qualitative study, I employed framework analysis 

outlined by Ritchie and Spencer (1994) and expanded on by Gale et al. (2013). Framework 

analysis methodology involves seven procedural stages of analysis: (1) transcription/data 

organization, (2) familiarizing, (3) coding, (4) developing an analytical framework, (5) applying 

an analytical framework, (6) charting data into framework matrix, and (7) interpreting the data 

(Gale et al., 2013). 

Transcription. As noted, participant interviews were transcribed verbatim. At the time of 

transcription, I assigned participants pseudonym codes, and all participant information was de-

identified, including participant names, identifying information, and therapist information. Data 

were stored digitally in Microsoft Word files with an encrypted passcode to ensure secure 

storage. I used a codebook that included categories for terms, emerging themes, and notes, which 

52 

 
 
 
I maintained to organize initial categories and accessible information during later stages of 

analysis. Computer Assisted Qualitative Data Analysis Software (CAQDAS) is considered 

useful for this form of research due to the magnitude of data collected, and therefore, the study 

design was modeled under the guidelines of prior studies using the MaxQDA qualitative coding 

software (Parkinson et al., 2016; Ward et al., 2013). 

Familiarizing. The second stage of framework analysis included an iterative and 

immersive process of reading all interviews in their entirety multiple times, paired with memo 

taking (Creswell & Poth, 2018; Gale et al., 2013). This process allowed me to develop a “sense 

of the data as a whole without getting caught up in the details of coding” (Creswell & Poth 2018, 

p. 148). This process spanned across six months between the first and final interviews. 

Consistent familiarization (reading, listening, and memoing) of each case and across cases 

enabled me to develop an overarching understanding of what participants communicated during 

the interview process, which supported the initial coding framework for emergent themes. 

Memoing also serves a vital role as an “audit trail” (Creswell & Poth, 2018, p. 149) to support 

the development of codes throughout the process of analysis. This information was shared in 

detail with my advisor in ongoing analysis meetings in which we developed the emergent 

framework based on memos, which included key phrases, concepts, and themes from the data. 

The emergent framework consisted of a moderate number (i.e., less than 10) of general 

categories of information per research question, and that were consistently supported by the data, 

which served as an initial guide for in-depth systematic analysis.  

Coding. The next phase of analysis involved line-by-line open coding in MaxQDA to 

further identify emergent themes that were inductive and that defined “particular behaviors, 

incidents, or structures” in the data, such as pervasive expressions, experiences, or emotions 

53 

 
 
 
(Gale et al. 2013, p. 4). Open coding elaborated upon and determined more specific themes in the 

data based on the emergent framework in the prior section. At this stage, I built “detailed 

descriptions, appl[ied] codes, develop[ed] themes or dimensions, and provide[d] an interpretation 

in light of . . . the literature” (Creswell & Poth, 2018, p. 151). Coding in this stage involved 

aggregating the data to develop “small categories of information” that was used to compare 

codes across cases (Creswell & Poth, 2018, p. 151). Once all categories were determined, they 

were designated with a specific name, a description of each category, and a code, in addition to a 

designated example of the code from the data itself. 

Developing an analytical framework. To develop a working analytical framework, the 

research team, consisting of myself and my advisor, met in order to categorize and define codes 

by integrating emergent themes and prior categories based on CPTSD symptomology and 

attachment theory. This was an iterative process that took place after the initial coding of the first 

three transcripts, and it continued until each transcript had been fully coded. Furthermore, the 

data were interpreted considering the a priori concerns within the current traumatic stress and 

systemic therapy literature regarding CPTSD symptomology, adult attachment, and mechanisms 

of change for CPTSD interventions. To support the trustworthiness of the study findings (Braun 

& Clarke, 2006; Pelias, 2019), once the analytical framework was initially identified by the 

research team, study participants had the opportunity to review categories and offer approval or 

input for adjustment. Responding participants (n=12) overarchingly agreed with the content of 

the framework and provided feedback about certain elements that they felt needed to be 

highlighted—for example, the essential nature of validation in therapy and between partners in 

the context of past trauma, and the need for therapists to direct clients toward their core emotions 

and away from content.  

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Applying analytical framework. The application of the analytical framework began 

directly following the initial iterations of framework development prior to completing coding for 

all transcripts. The framework was then applied by indexing remaining transcripts using the 

framework for existing categories and codes based on a priori concerns and emergent themes. 

The application was also an iterative process that took place amongst coding and framework 

development as new themes arose (Gale et al., 2013). This process of applying the framework 

was assisted by MaxQDA, which supported the process of cross-checking between researchers in 

the next stage and aided in clarity as well as organization for a research team where I led the 

primary coding process (Gale et al., 2013; Parkinson et al., 2016). 

Charting data into framework matrix. A key element of framework analysis involved 

charting the data into a matrix to clearly organize and reduce “voluminous” data (Gale et al, 

2013, p. 5). This is a useful method for qualitative health research with large data sets, consisting 

of multiple hours of interviews across cases. The framework matrix made it easier to “identify 

relevant data extracts to illustrate themes and to check whether there is sufficient evidence for a 

proposed theme” while also providing an “audit trail from original raw data to final themes, 

including the illustrative quotes” (Gale, 2013, p. 6). Early in this stage, it was important to 

address trustworthiness in qualitative interpretation in order to compare and contrast 

summarizing across the research team, which was done in an iterative process as interviews were 

completed. Charting into the framework matrix supported the summarization of data within the 

context of each participant couple case as recommended by Gale et al. (2013), which aided the 

organization of “complex meaning and understanding” by using “each participant’s own 

subjective frames” (Gale et al., 2013, p. 5). This process helped to ensure transparency in the 

55 

 
 
 
coding process from charting to interpretation between the research team. The final framework 

matrices are listed in Appendix H and Appendix I.  

Interpreting the data. After all the interviews were coded in MaxQDA and then charted 

into the framework matrix, a data summary was added for each category and participant in each 

RQ domain. At this stage, the research team—my adviser and myself, who are both clinician 

researchers with varying degrees of experience—explored the data categories and themes and 

compared interpretations. This process allowed for a critical look at our interpretation of 

participants’ experiences from various perspectives and bolstered our confidence in the 

robustness of our analysis and findings. We each brought both unique and convergent 

perspectives to the analysis. As traumatic stress researchers and clinicians, we drew from our 

familiarity with the theoretical and empirical literature along with our clinical experience with 

trauma exposed couples. Being responsible for the collection of data, including qualitative 

interviews, I was more intimately aware of each participant couple’s experience, while my 

research advisor was able to challenge my interpretations in the light of prior research. 

Compilation of the data led to a final iteration of interpretation, which led to a further refinement 

of themes, increasing our confidence in the robustness of our analysis and its ability to relay and 

summarize the experience of couples in the context of CPTSD and EFT treatment.  

Following the completion of the framework analysis, data were written up in two distinct 

manuscripts that separated findings between CPTSD couples experiences’ of symptomology in 

their relationship and their perspectives and experiences of the EFT intervention. 

Trustworthiness. An essential element of qualitative research is establishing credibility 

though rigorous methodology (Creswell & Poth, 2018). For this study, I acted as the primary 

researcher, interviewer, and qualitative coder. Because I performed multiple roles in this study, I 

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built in several stages of cross-checking and member-checking to support the confirmability and 

dependability of the study findings. Cross-checking for this study involved my advisor as an 

expert in the field of couples therapy, EFT, qualitative data analysis, and trauma in couple 

relationships. Furthermore, I elected to use a study design and audit trail that prioritized an 

organization and transparency with those involved in cross-checking with my research 

committee. Additionally, the dependability of the results was supported by member-checking, as 

outlined by a similar study (Dansby Olufowote et al., 2020), which offered participant 

involvement that provided commentary on the findings during the initial theme coding stage.  

Reflexivity 

Qualitative methodology acknowledges the role of the researcher as an active ingredient 

in the study design, analysis, and interpretation (Creswell & Poth, 2018). Pelias (2019) maintains 

that in all research, especially qualitative methodology, it is essential that researchers are both 

“ethically and politically self-aware, (and) make themselves part of their own inquiry” (p. 662). 

As the primary researcher of this study, I recognize my positionality as a Caucasian American, 

cis-gendered female in my early thirties. I am also a couple and family therapist and researcher 

with ten years of experience in the field. I have been trained in several systemic therapy and 

trauma therapy models with a special emphasis on Eye Movement Desensitization and 

Reprocessing Trauma Therapy (EMDR) and EFT. I practice from an attachment and trauma-

informed lens, and my work is influenced by social justice and feminist theories. Furthermore, I 

acknowledge the presence of my own attachment, interpersonal trauma, and relational 

experiences and their impact on my worldview as a researcher in addition to my preexisting 

clinical and empirical conceptualizations of CPTSD and EFT. 

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Through the awareness of my own positionality, I pledged to privilege the voices, 

perspectives, and interpretations of the study participants. As the primary researcher for this 

study, I maintained a reflexive stance and consistently met with my study advisor to discuss how 

my prior training, clinical experiences, and prior research in systemic and trauma-informed 

therapies influenced my conceptualization and interpretation of the results. Additionally, to avoid 

marginalizing participants’ perspectives, the research process was conducted as an interactive co-

construction between the researcher and participants. Once core themes were determined, study 

participants had the option to review and provide input into preliminary findings. 

Feasibility, Ethics, and Limitations 

It was essential that the therapists included as recruitment liaisons clinically practice out 

of the EFT paradigm and routinely participate in ongoing education in the model, which entails 

gaining client consent for filming sessions. This engagement showed promise for the feasibility 

of the study due to a population of therapists and clients who displayed a preexisting willingness 

to participate in actions that further research and best practices in EFT. Furthermore, from the 

participating sample of EFT therapists, there were 47 therapists who all maintain full clinical 

caseloads, which therefore included over 1,500 clinical couples.  

In terms of feasibility and ethics, it was my belief as a trauma researcher and clinician 

that couples could engage in this research and benefit from the insight into their experiences by 

participating in this study, which was supported by research with similar populations (Chouliara 

et al., 2012; Matheson & Weightman, 2020; Stadtmann, 2017). As a trauma-informed researcher, 

psychological safety is a foundational element of this study. Therefore, I took all possible 

measures to establish an ethical methodology in this study, including acknowledging I would end 

or redirect an interview when participants or I deemed that proceeding could cause any 

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psychological or relational harm. This did not occur; however, participants were informed of this 

procedure. A key limitation of this study is that it recruited couples who were extremely open to 

share about their experience in a joint interview and who were actively seeking treatment for 

their relational issues. Therefore, this sample did not represent the full scope of CPTSD impacted 

couples but rather focused on a subset of the study population.  

Summary 

Empirical literature investigating foundational components for CPTSD intervention 

overwhelmingly recognizes the need to expand relational treatments for CPTSD that can focus 

on the “rebuilding of relationships based on trust (as) an active mechanism of change” 

(Matheson & Weightman, 2020, p. 1). Current findings from both the traumatology and systemic 

family therapy literature recognize the inherent value of systemic conceptualization and 

treatment for those with accumulated interpersonal trauma (Suomi et al., 2019; Vaillancourt-

Morel et al., 2019). Much of the work in this area for adults has been explored with Emotionally 

Focused Couple therapy(EFT) with promising preliminary evidence (Dalton et al., 2013; 

Johnson, 2019; Roundy, 2017). The phenomenological approach for this study advantaged the 

current state of the literature for CPTSD by revealing the perceived acceptability and impact of 

EFT for couples who experience the impact of CPTSD in their relationship in addition to giving 

voice to the CPTSD’s effect on intimate partner relationships. A strength of the proposed study is 

that it sought to integrate two siloed empirical fields of study that each investigate effective 

interventions for CPTSD and interpersonal trauma. This study merged developing theories and 

clinical perspectives from EFT, systemic family therapy, and complex trauma literature by using 

a bottom-up approach to privilege the perspectives of the population itself to inform future 

research. 

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CHAPTER 4: STUDY ONE—COUPLES’ EXPERIENCES OF CPTSD 

SYMPTOMATOLOGY 

Abstract  

Complex Post Traumatic Stress Disorder (CPTSD) has been designated as the most 

functionally impairing form of traumatic stress response. CPTSD is distinct from PTSD in both 

the type of trauma exposure that leads to CPTSD and in symptom presentation. The CPTSD 

diagnosis includes a cluster of symptoms designated as a Disorganized Sense of Self (DSO) in 

addition to PTSD symptomology. The types of trauma exposures that lead to CPTSD are 

repeated forms of interpersonal trauma that are typically experienced within the context of close 

attachment relationships such as childhood sexual abuse, intimate partner violence, emotional 

abuse, and adverse childhood experiences. Due to the interpersonal nature of trauma exposures 

related to CPTSD and the severity of symptoms, close interpersonal relationships, especially 

intimate partner relationships, are greatly affected. However, little is known about how 

individuals and their partners experience, manage, and understand the impact of CPTSD-specific 

symptomology within their relationships. Therefore, the current study used a qualitative 

approach informed by framework analysis to explore ten client couples’ experiences of CPTSD 

symptomology within the context of their relationships. Findings revealed the immensity of 

symptom burden for couples and the degenerative impact of CPTSD symptomology on their 

relationship in addition to the meaningful ways couples were able to jointly manage and cope 

with symptoms. Clinical implications and directions for future research are discussed.  

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Introduction  

Empirical literature has identified the critical importance of close and fulfilling 

relationships in human survival, well-being, longevity, and physical health (Fyvie et al., 2019; 

Gerge, 2020; Mahoney et al., 2019; Matheson, & Weightman, 2020). Conversely, exposure to 

prolonged and repeated interpersonal trauma can create a cascade of harmful symptomology 

attached to trauma-related stimuli in the context of relationships, which hinders their protective 

factors (Hyland et al., 2017b; Matheson, & Weightman, 2020; Stadtmann et al., 2018). Complex 

Post Traumatic Stress Disorder (CPTSD) has been identified as a traumatic stress disorder, 

distinct from PTSD, which develops from exposures to trauma and abuse within close 

relationships (Cloitre et al., 2018; Herman, 1997; Hyland et al., 2017b). Untreated CPTSD 

symptomology has a degenerative impact on all aspects of human life, including mental health, 

relationships, physical health, and mortality (Cloitre et al., 2019; Hyland et al., 2017a; Karatzias 

et al., 2016; 2017; 2019). Consequently, a number of organizations around the world, most 

prominently, the World Health Organization (Hyland et al., 2017b), have classified it as an 

epidemiological issue of great concern. 

CPTSD as a Distinct Traumatic Stress Disorder  

For decades, PTSD has been the primary traumatic stress diagnosis from which clinicians 

and researchers operate to develop effective therapeutic interventions for trauma (Cloitre et al., 

2011). PTSD criteria include three core symptoms: avoidance, hypervigilance, and 

reexperiencing (Hyland et al., 2017b). The eleventh edition of the International Classification of 

Diseases (ICD-11) operationalized an additional cluster of symptoms that are a component of the 

CPTSD diagnosis that are referred to as a disorganized sense of self (DSO) (Cloitre et al., 2018; 

Hyland et al., 2017; ICD-11). The DSO symptom clusters include emotion regulation difficulties, 

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negative self-concept, and disturbances in relationships, which, in addition to PTSD 

symptomology, make up the CPTSD diagnosis (Cloitre et al., 2018; ICD-11; Shevlin et al., 

2018). Critically, empirical research recognizes the severity of, and functionally impairing nature 

of CPTSD symptomology compared to PTSD alone (Herman, 1992; Hyland et al., 2017b). It is 

believed that the deeply rooted interpersonal nature of CPTSD trauma symptoms and exposure 

intensify the experience and frequency of symptomology because the trauma stimulus—

relationships—are complex and serve as a commonplace experience necessary for survival 

(Chouliara & Narang, 2017; Cloitre, 2015; Herman, 1997).  

Trauma type. The empirical literature has identified the importance of trauma type as a 

predisposing factor for how individuals develop a traumatic stress response (Maercker et al., 

2013; 2022). Known interpersonal trauma exposures, which predict CPTSD diagnosis, include 

adverse childhood experiences (ACES), childhood sexual abuse, emotional abuse, prolonged 

domestic violence, institutional abuse, and refugee status (Knefel, 2019; Melton et al., 2020). 

Exposure to these types of interpersonal trauma is prevalent in every community worldwide 

(Hyland et al., 2017a). Furthermore, prevalence studies indicate CPTSD is more prevalent than 

PTSD in general among trauma-exposed and treatment-seeking populations globally (Karatzias 

et al., 2017; Redican et al., 2022).  

Attachment and CPTSD. CPTSD and related interpersonal trauma research has begun 

to make the connection between the underlying mechanisms of trauma experienced within 

relationships and Bowlby’s theory of attachment (Bowlby, 1988; Bretherton & Munholland, 

1999; Dansby Olufowote et al., 2020; Linder et al., 2022a). Attachment theory maintains that 

human connection is a core feature of survival. Therefore, when interpersonal and/or emotional 

proximity, responsiveness, and safety is violated, this creates an attachment wound and incites an 

62 

 
 
 
insecure attachment style or way of relating to others (Aloni et al., 2020; Bowlby, 1988). 

Insecure attachment styles—including avoidant attachment, anxious attachment, or disorganized 

attachment—all stem from pervasive attachment wounds with caregivers or close others, and 

they result in subsequent fear-based beliefs and patterns of relating to others in close 

relationships (Alexander, 1992; 2012). In relation to CPTSD, pervasive patterns of interpersonal 

trauma are viewed in the light of attachment wounds, which can impact individuals’ ability to 

feel safe and secure in close relationships (Atkinson, 1997; Liotti, 2013). The underlying 

attachment-based mechanisms of CPTSD promote a state of fearfulness and distress, especially 

within the context of close relationships (Liotti, 2013). The impact of these symptoms is most 

notable for adults in their intimate relationships with romantic partners, which has generated 

increased interest in the study of adult attachment and its interplay with relationship functioning 

in couple therapy (Cassidy & Mohr, 2001; Nivison et al., 2022). Research indicates that 

individuals with CPTSD-related sequela struggle in relationships due to untreated or unaddressed 

attachment-related traumas (Atkinson, 1997; Lotti, 2013). Furthermore, the adult attachment 

literature underscores the importance of establishing a secure attachment between partners in the 

context of attachment-based relational distress (Cassidy & Mohr, 2001; Dansby Olufowote et al., 

2020; Linder et al., 2022a, 2022b; Nivison et al., 2022). Additionally, initial empirical research 

supports the expansion of attachment-based conceptualizations for CPTSD, which can support 

intervention research using attachment-based models (Aloni et al., 2020; Fyvie et al., 2019; 

Johnson, 2019; Karatzias et al., 2018b; Pearlman et al., 2005)  

CPTSD treatment gap. Due to the differences in trauma response and the relatively new 

classification of CPTSD as a distinct disorder, empirical research on effective treatments for 

CPTSD is lacking (Brewin, 2020; Bryant, 2022; Forbes et al., 2020). Addressing the critical 

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CPTSD treatment gap in evidence-based interventions is a primary concern of the traumatology 

field at this time (Karatzias et al., 2019b). Empirical literature supports the effectiveness of 

evidence-based traumatic stress interventions for PTSD-specific symptomology; however, this 

support is limited to only effectively treating PTSD symptoms (Herman, 1992; Hyland et al., 

2017a). Outcome research indicates that standard traumatic stress interventions, such as trauma-

focused CBT and exposure therapies, do not adequately address the full scope of CPTSD 

symptomology (Karatzias et al., 2019c; Matheson & Weightman, 2020; Monson et al., 2022).  

Those who suffer from CPTSD often have a disorganized ability to regulate emotions. 

Consequently, they have difficulties relating to themselves and others (Karatzias et al., 2018a; 

2018b; Knefel et al., 2019). Because of these difficulties, those with CPTSD often find that 

relationships can be extremely distressing and, unfortunately, they can become trapped in a 

perpetual cycle of re-traumatization (Alexander, 2012; Karatzias et al., 2019a). As researchers 

learn more about CPTSD, it is becoming more clear that, due to the nature and intricacies of 

CPTSD, a one-size-fits-all approach to trauma intervention is not working (Fyvie et al., 2019; 

Gerge, 2020). Clinical observations suggest that current interventions need to be expanded to 

include relational interventions (Cloitre et al., 2011; Fyvie et al., 2019). The fields of 

traumatology and couple therapy, however, largely operate in isolation (Brewin, 2020; 

MacIntosh, 2018). More specifically, there is a great need for research that provides information 

about the ways in which individuals with CPTSD experience relationships and how practitioners 

can tailor interventions to impact those experiencing CPTSD symptomology (Cloitre & 

Karatzias, 2019; Karatzias et al., 2019b; Matheson & Weightman, 2020). 

Inquiry into candidate CPTSD interventions. Current studies acknowledge the 

importance of continuing the development of comprehensive understanding, as well as effective 

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interventions, on the ways individuals with CPTSD experience the disorder (Melton et al., 2020; 

Stadtmann, 2017; 2018). The current evidence-based interventions for traumatic symptomology 

were developed specifically for PTSD, which does not account for the more severe DSO 

symptom clusters and root interpersonal trauma stimuli (Bryant, 2022; Karatzias et al., 2019b; 

Mahoney et al., 2019). In order to bridge the gap between the current trauma interventions and 

efficacious approaches for CPTSD treatment, interventionists currently “rely heavily on clinical 

experience and theory,” despite the fact that “there is usually sparse empirical evidence in terms 

of effects, and acceptability from the patient or therapist perspective” (Chouliara et al., 2017, p. 

3). 

Despite evident overlaps between interpersonal functioning and CPTSD, there has been 

relatively little research concerning how couples that include at least one individual with CPTSD 

experience, think about, and manage the disorder. This is the case even though we know that 

along with CPTSD’s attachment and neurobiological factors, research into interpersonal trauma 

types has shown that relationships between intimate partners can trigger interpersonal traumas 

that have not yet been resolved (Barawi et al., 2019). 

Consequently, there is a need for further inquiries that use qualitative methods for 

determining the lived experiences of people with CPTSD. Additionally, research should address 

these individuals’ perspectives concerning the potential fit, acceptability, and adaptation of 

treatments targeting CPTSD’s underlying intrapersonal and interpersonal factors (Boullier et al., 

2018; Cloitre et al., 2011; Karatzias & Levendosky, 2019).  

Present Study  

A deeper and more comprehensive understanding of CPTSD interventions is greatly needed 

at this time in order to better support those who experience CPTSD as well as their families 

65 

 
 
 
(Melton et al. 2020). This knowledge will add to the current scholarly literature on the subject, 

which has demonstrated the potential effectiveness of relational interventions in treating CPTSD 

(Cloitre & Karatzias, 2019; Matheson & Weightman, 2020). This study seeks to explore the 

ways that couples—in which one or both of them has experienced CPTSD—experience 

interpersonal-related trauma symptoms in their relationship. The proposed study explores the 

following question: 

How do individuals with CPTSD and their partners experience, manage, and perceive the 

impact of CPTSD-specific symptomology (i.e., reexperiencing, hypervigilance, 

avoidance, disturbances in relationships, emotion regulation difficulties, and 

negative self-concept) within the context of their intimate relationship? 

Method 

Recruitment. All study procedures were approved by Michigan State University’s 

Internal Review Board. Recruitment for the current study took place over two ongoing stages 

across the open recruitment period of November 2021 and June 2022. This study’s first stage of 

recruitment involved using community engaged, purposive, convenience, and snowball sampling 

methodology with EFT couple therapists who had access to couples seeking treatment for 

interpersonal-trauma-related relationship distress. Participating therapists acted as recruitment 

liaisons (Archibald & Munce, 2015). Stage two of the recruitment process involved therapists 

posting the study flyer (Appendix A) in their offices and/or providing the study flyer directly to 

couple clients who had reported exposures of interpersonal trauma. Therapists were asked to 

clarify that the study was not required and that it was completely separate from their therapeutic 

work. The recruitment materials directed clients to the study website, where participants could 

find more information about the study’s format, which entailed a joint Zoom interview with 

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couples, and a link to the client screening survey. Recruitment for this study took place over an 

eight-month period and ended once the study reached 10 couples and qualitative data indicated 

saturation. 

Screening and eligibility. There were multiple levels of screening in this study. First, the 

study screened the eligibility of recruitment therapists. To meet this eligibility criteria, therapists 

had to be licensed, and meet a minimum training requirement of completing the four-day EFT 

externship, and the two additional twelve-hour EFT core skills courses (core skills 1 and 2) 

(Appendix E). Then, the screening processes determined eligibility of the participating EFT 

therapists’ client couples who elected to take the screening survey. The client screening process 

entailed four primary eligibility considerations: (1) couples had to be involved in a committed 

relationship with each other for a least six months, and they both had to be at least 18 years old, 

(2) they had to currently be involved in EFT treatment—with an eligible EFT therapist—for a 

minimum of eight weeks prior to their participation in the study to ensure they could speak to 

their experiences with EFT, (3) each partner had to fill out the screening survey, providing 

matching names (their own and their partner’s), emails, locations, EFT therapists, and their time 

in treatment, (4) at least one of the partners had to meet the criteria for CPTSD, as measured by 

the International Trauma Questionnaire (ITQ) (Appendix F), and (5) both participating partners 

had to willfully take part in the joint interview. A follow-up survey—which asked about 

demographic information and included an informed consent form and a scheduling form for the 

interview—was sent to those participants who passed the initial screening.  

Measures. 

Demographics. This study used a standard demographic screening that asked general 

questions about potential participants’ age, gender, race and ethnicity, level of education, 

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socioeconomic status, relationship status, the amount of time of their current relationship, 

number of children, and the length of time they had been involved with EFT (Appendix, D).  

International Trauma Questionnaire. The International Trauma Questionnaire (Appendix 

F) is the only valid, reliable tool that can help distinguish PTSD and CPTSD as distinct disorders 

(Cloitre et al., 2018; Shevlin et al., 2018). The questionnaire includes 18 questions that all use 

the Likert scale. In order to support the ITQ’s ability to diagnose likely CPTSD and PTSD, the 

questionnaire has been validated independently (McElroy et al., 2018). It has also been validated 

by being administered to diverse populations with varying ages, location, and types of trauma 

(Fernández-Fillol et al., 2020; Haselgruber et al., 2019). Because it is currently the only tool that 

can validly measure and assess CPTSD, the ITQ is an appropriate tool for this study. 

In this study, participants received the questionnaire with the first Qualtrics screening 

survey. If either member of the couple did not meet the clinical requirements of CPTSD—16 out 

of a possible 72—they could not participate in the study. Questionnaire scores are derived from 

individual scores that are equal or greater than two, which is a moderate score for each symptom 

of PTSD (avoidance, hypervigilance, and reexperiencing) and DSO (emotion regulation 

difficulties, negative self-concept, and disturbances in relationships). Additionally, a CPTSD 

diagnosis must involve moderate levels of functional impairment indicated by a score of two or 

higher for functional impairment in each of the PTSD and DSO categories. Participant scores 

indicating PTSD, DSO, functional impairment, and the total scores for each participant are 

summarized in Table 2. Based on ITQ scoring, the overwhelming majority of the sample met the 

criteria for CPTSD (n=19) as per their self-report scores of 16 or above across the PTSD, DSO, 

and functional impairment scoring categories from the ITQ in the screening survey (Appendix C, 

and F). Participants had an average score of 38 out of a possible 72 (range=22–61). Notably, 

68 

 
 
 
participants scored relatively high for CPTSD, indicating the severity of symptoms across the 

sample. Additionally, partner’s scores within each participant couple ranged somewhat close 

together with the average difference of 10 points between partners (range=2-22).  

Enrollment. Participants with screening materials who met the study’s inclusion criteria 

were then offered the study’s informed consent form (Appendix B). They were considered as 

officially enrolled in the study when they completed this form.  

Sample. After the screening process, a total of 12 couples (24 participants) fulfilled the 

study’s inclusion criteria. Two couples, however, later chose not to participate in the joint 

interview because of scheduling conflicts. As a result, the total sample size was 10 couples (20 

participants).  

Participant demographics. Participants for this study included 10 couples, or 20 total 

individuals. Overall, participants in the sample consisted of 40% males (n=8) and 60% females 

(n=12). Participants’ ages ranged between 25 and 65+ years old. Most participants (80%) were 

married (n=16), while 10% reported being in a committed relationship (n=2), and 10% reported 

being in a committed dating relationship after their divorce (n=2). The length of relationships 

ranged between 3 and 42 years, with an average of 17 years. Participants’ sexual orientation 

varied, with 75% identifying as heterosexual (n=15), 10% identifying as queer (n=2), 5% 

identifying as lesbian, (n=1), 5% identifying as bisexual (n=1), and 5% identifying as pansexual 

(n=1). All participants lived within the United States, with 50% in the Northeast (n=10), 20% in 

the Southwest (n=4), 20% in the West (n=4), and 10% in the Midwest (n=2). This was an sample 

with relatively high SES; the majority of participants (65%) reported a gross income of $100,000 

or higher (n=13), 20% making $80,000–$99,000 (n=4), 10% making $60,000–$79,000 (n=2), 

and 5% making $40,000–$59,000 (n=1). 

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Interview procedure. After screening, the qualifying couples were interviewed using a 

semi-structured interview guide (Appendix G). The interviews occurred online and were 

recorded using HIPPA-compliant Zoom meeting session software. Before the interview began, I 

orally went over the informed consent, reviewed the study’s goals and questions, summarized the 

study’s benefits and risks, and informed the participants that they could choose to skip questions 

or end their participation in the study at any point. Once the participating couples provided final 

verbal consent, the interviews began. 

Interview. The interview (Appendix G) did not ask about any details concerning 

participants’ past trauma that had been reported either in the screening survey or through another 

source. It did, however, acknowledge participants’ experiences of past trauma and ongoing 

CPTSD symptomology. As a result, the questions did not pertain to any past traumas but instead 

solely focused on the participants’ current lived experiences of trauma symptomology within 

their relationship. Partners were asked questions in an alternating format, which gave both of 

them an equal opportunity to respond.  

Data collection.  The qualitative interviews with the couples ranged between 78 and 134 

minutes and were an average of 120 minutes in length. The interview data resulted in rich 

descriptions of participant couples’ experiences of each PTSD and DSO symptom and the 

subsequent impact of these symptoms on their relationship. The interviews were recorded on 

Zoom video conferencing software and then password protected and stored electronically. Once 

transcribed, interviews were stored in Word files and kept under the same electronic password 

protection standards as the audio files. 

Data analysis. Framework analysis, a subset of thematic analysis outlined by Ritchie and 

Spencer (1994) and expanded by Gale et al. (2013), was used to analyze the large qualitative data 

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set for this study. As Gale et al. suggest, this methodology includes seven steps of analysis: (1) 

the transcription and organization of data, (2) data familiarization, (3) coding, (4) creating a 

framework for analysis, (5) applying the framework, (6) placing data into the framework matrix, 

and (7) data interpretation (2013).  

Following the methods outlined above, participant interviews were transcribed verbatim, 

de-identified, and each participant was assigned a pseudonym code. Transcription data were 

stored with an encrypted passcode to ensure secure storage digitally in Microsoft Word files. As 

the interviewer and lead researcher for this study, I kept track of initial categories for terms, 

emerging themes, and notes after each interview in a codebook, which supported organization in 

early stages of analysis. As standard for large datasets in framework analysis studies, I used a 

Computer Assisted Qualitative Data Analysis Software (CAQDAS), MaxQDA (Parkinson et al., 

2016; Ward et al., 2013). The next stage of analysis, spanned across six months (i.e., between the 

first and last interview), and involved a continual process of reviewing each interview in depth 

multiple times while taking notes and memos in each iteration of familiarization (Creswell & 

Poth, 2018; Gale et al., 2013). From this, I developed an intimate understanding of the overall 

themes that participants relayed within and across interviews (Creswell & Poth 2018). The 

information from this stage was saved in the initial codebook as an audit trail (Creswell & Poth, 

2018), which I shared in detail with my advisor as we worked over time to develop the emergent 

analytic framework for the study.  

Once we developed the initial coding categories based on key themes within the data and 

a priori concerns, I began line-by-line open coding in MaxQDA to further classify emergent 

themes that were inductive and that portrayed “particular behaviors, incidents, or structures” in 

the data across cases (Gale et al. 2013, p. 4). From this stage, the we worked to develop a core 

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analytical framework which involved defining coding categories and in an iterative fashion with 

the completion of each interview. As an important aspect of this analysis, this stage to 

incorporated study participants perspectives of the analytical framework (Braun & Clarke, 2006; 

Pelias, 2019). The responding study participants (n=12) provided feedback about certain 

elements that they felt were important within the framework, which included: validation between 

partners in the context of past trauma, and interpersonal healing and the development towards 

understanding their own and each other’s symptoms.  

The next stage was to apply analytical framework, which involved indexing each 

interview transcript codes into the matrix to compare existing categories and codes across cases. 

The application stage was again, an iterative process, which developed amongst coding and 

framework development as new themes evolved and as we received feedback from participants 

(Gale et al., 2013). The next essential stage of analysis was charting data into framework matrix. 

The charting stage included organizing the data by reducing it from lengthy sets of codes across 

cases from “each participant’s own subjective frames” (Gale et al., 2013, p. 5), into salient 

summaries of each theme. Once all of the data was fully charted within the analytic framework 

categories, I met with my advisor repeatedly to cross-check and compare interpretations of each 

code category and theme. Through this iterative interpretation process, we determined six 

categories based on each CPTSD symptom each with a subset of themes related to how couples 

experienced CPTSD symptomology within the relationship, how they coped, and the relational 

impact of each symptom (Appendix H). 

Trustworthiness. Central to the trustworthiness of qualitative research is the creditability 

and confirmability of the analysis (Creswell & Poth, 2018). In the current study, I held multiple 

roles in this study, as the primary researcher, interviewer, and qualitative coder. Therefore, I built 

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in multiple layers of both cross-checking and member-checking to support the confirmability and 

dependability of the study findings. Cross checking for this study primarily involved my research 

advisor who is experienced in the field of couples therapy, trauma in couple relationships, EFT, 

qualitative data analysis. Importantly, the confirmability of the analysis is supported by member-

checking, which was used in similar study (Dansby Olufowote et al., 2020). Member-checking in 

this framework solicited participant involvement and requested their input on the initial 

analytical framework, theme categories and summaries. Their feedback supported the direction 

of what they, as participants, found the most important in based on their experience as couples in 

the context of CPTSD symptomology.    

Results 

The findings from the current study outline couples’ experiences of each distinct CPTSD 

symptom (hypervigilance, avoidance, reexperiencing, negative self-concept, emotion regulation 

difficulties, and disturbances in relationships). The findings further identify couples’ perceptions 

of the impact CPTSD symptoms have on their relationship and their process of coping with 

symptomology over time.  

PTSD: Avoidance. 

Experience of avoidance: Couples consistently avoided relational trauma stimuli within 

their relationship. Participants in the current study described their experience of avoidance in 

depth and distinguished between intentional versus unconscious avoidance and how these 

symptoms were directly related to past interpersonal traumas. They also described the relational 

impact of both forms of avoidance, their journey to identify and understand this symptom in the 

context of past trauma, and their attempts to manage it within their current relationship. 

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Avoidance for participants in the sample was a deeply ingrained and consistent symptom. 

This was the case individually—“I became an expert at avoiding, you know, now that I’m 

thinking about it is probably one of my best go-tos” (Cathy)—but it was also the case within 

their intimate relationship as a way to avoid conflict—“we have a well-ingrained habits of 

avoiding, you know, all those sorts of raw spots that we have from our childhoods and from, you 

know, our early relationship when things were less stable” (Gina). In this way, participants 

within the sample described avoidance as a coping mechanism that was in some ways intentional 

and protective—“I mean, there are certain things about the trauma that I’ve experienced that I 

know there are certain situations that will bring that up for me and I avoid them” (Amy). 

However, participants also experienced avoidance like an involuntary “preprogramed reaction” 

(Evan). One participant, Cathy, further described avoidance in this way:  

There’s different kinds of avoidance, like the avoidance that helps protect us and to help 

keep us safe and healthy. . . . I think the other part of the question is avoiding things that I 

don’t even realize I’m avoiding. And, and that does happen. 

These two forms of avoidance experienced by participants played out in their relationship in both 

intentional and unintentional ways and with associated conscious and unconscious reactions, 

which affected how they encountered their relationship on a regular basis. Whether healthy or 

not, avoidance within the relationship served as a mechanism partners could use to create space 

and feel safe from distressing stimuli, including either their own or their partner’s difficult 

emotions (which is related to emotion regulation difficulties and reexperiencing). As Cathy 

explained: 

Sometimes [my partner] recognizes [my avoidance] . . . she’ll say that I’m distant . . . but 

I don’t even recognize it when I’m emotionally avoidant. So, in the past, I didn’t even 

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know what [my partner was] talking about. Then I would become really defensive and 

irritable because I’m distant for a reason. Like, I just don’t want you to bother me. I don’t 

want anybody to bug me kind of thing. 

Participants further relayed how these forms of avoidance were intended to prevent 

negative interactions in their relationships (disturbance in relationships) related to painful 

emotional states (emotion regulation difficulties) or sensitive situations connected to past trauma 

(reexperiencing), or fears of attachment loss within the current relationship (hypervigilance, 

negative self-concept). Participant Amy revealed, “I do avoid conflict with [my partner] a lot of 

the time because it brings up, like, bad emotional feelings and bad memories for me about 

conflicts that I’ve had in the past.” Participant Brent further detailed the role of avoidance as a 

stabilization tool amidst overwhelming stimuli in his personal experience and relationship:  

I think I spent several years avoiding internal feelings and thoughts related to my own 

trauma. I’ve done a lot of work . . . to sort of face those things, but I still do it. I mean, 

there’s certain things I don’t want to think about or put myself in a position, and I will 

definitely avoid things that might trigger [my partner], I guess. So, I’m still very aware of 

that kind of stuff. . . . I guess I’ve got sort of a PhD in sensing when things are about to 

explode or get scary.  

His partner, Monica, then responded, “(my partner) is very attuned to, like, my triggers, and 

maybe he’s had to be that way.” 

Experience of avoidance: Withdrawal and disassociation led to distance and 

disconnection between partners. Participants described the impact of avoidance symptoms on 

their relationship. Partners relayed that their external responses took the form of emotional 

disconnection via withdrawal. For example, one participant, Brent, noted, “I see it in myself, if I 

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feel something familiar [to past trauma] in my marriage, my go-to coping mechanism is to 

withdraw.” Brent’s partner, Rachel, noted how her external response took the form of 

disassociation: “the question [of avoidance] is a little bit difficult for me because I dissociate 

regularly, it’s not conscious I’m avoiding [my partner].” 

Relational impact of avoidance: Mutual activation of avoidance symptoms between 

partners. The pattern of withdrawal and disassociation rooted in trauma avoidance proved 

difficult for couples. Participants described a mutually activating cycle related to avoidance and 

systemic triggering of issues in partners: “If I sense my partner’s avoidance, I completely cut off 

[from him] . . . it’s my fear of abandonment” (Erica). Another explained her reaction to her 

partner’s avoidance based in the fear of attachment loss (related to hypervigilance) and 

disconnection:  

When he shuts down or, like, if he’s cold and distant to me, then it triggers something 

inside me . . . [when] he was very distant to me. Like my behaviors would ramp up. I 

would subconsciously, like, pick a fight or, like, text him a thousand times. Yeah. And he 

would make him even more distant. And I didn’t realize what I was doing was just, you 

know, trying to get his attention. (Brittney) 

The result of this mutually activating cycle surrounding partner avoidance, perceived as 

emotional distance, plays out further in couples’ experiences of the other five CPTSD symptoms 

(see below). In this way, avoidance-related constructs within participants’ relationships triggered 

frustration, anger, and constant arguments (emotion regulation difficulties), the replaying of past 

traumatic experiences in the present (reexperiencing), a heightened sense of fear and threat 

within the relationship (hypervigilance), feelings of being unloved and emotionally cut off from 

one’s partner (negative self-concept), and an unreliable attachment bond between the partner 

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(disturbances in relationships). These are detailed within each symptom category below. 

Avoidance seemed to play the role of preserving the relationship at times, or it kept a partner’s 

difficult emotional states at bay, but it also kicked off a mutually activating cycle that triggered 

other symptoms, which also stirred up relationship difficulties. 

Relational impact of avoidance: Avoidance of emotional and sexual intimacy. In terms of 

the relational impact, an emergent theme was the way in which couples’ sexual relationships 

were impacted by traumatic stress-related avoidance. As one participant, Kirsten, noted, “our 

sexual relationship is impacted because I will get to a certain point and then I get triggered.” 

Within the sample of this particular study, partners displayed compassion for their partners’ 

experiences, recognizing that “sexual activity is, is different for us than if (my partner) hadn’t 

had some things in her childhood” (Harry). In this case and in others, participants displayed a 

sense of empathy for their partner’s experience and yet described a lack of intimacy, pervasive 

sexual issues, or a lack of sexual frequency as core problems in their relationship. This was also 

met with a key realization from one participant (Janet), who noted that greater physical and 

emotional intimacy within her relationship was perceived as a heightened risk and, therefore, 

something to avoid due to her interpersonal trauma history:  

We started to see [a therapist because] of sexual issues that were related to [my partner’s] 

trauma and my needing to understand it, it was helpful to me to understand the issues in 

our relationship, but in order to do that, I had to understand the trauma history and how 

that, how that changed everything. Because the closer we got and the longer we were 

together . . . the more truly intimate we were, the more she got scared. (Janet) 

Managing and coping with avoidance: Lack of resolution. When asked how they manage 

these symptoms within their relationship, several participants responded by recognizing the 

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burden it had on their relationship. They noted their struggle to find a solution, but for many, 

they just learned to live with the lack of resolution. For example, “I don’t think we do manage. . . 

. I’m fight, [my partner is] flight. We need to find a new way” (Mitchell), or, “I’ve made clumsy 

attempts . . . but it hasn’t always been going well” (Adam).  

A process toward discovery and understanding. Conversely, some participants described 

a discovery phase and progression toward mutually managing the avoidance-response pattern as 

it related to their own and their partner’s avoidance. Participants described their experience, and 

their management of avoidance symptoms within the relationship, as a continual progression 

toward learning about the symptom in context and how to respond. This process was, at times, a 

confusing barrier and a painful reminder for partners, revealing the automatic and subconscious 

nature of their avoidance related to past interpersonal trauma and its pervasive impact on their 

current relationship.  

Within this process, participants described how long periods of conflict (reactivity) or 

emotional distance (emotional constriction) related to avoidance propelled partners to recognize 

the issue: “things got pretty explosive and that was damaging our relationship and we had to get 

help” (Monica). This course of discovery and the subsequent adaptive coping strategies for 

couples was heavily supported by extensive resources, primarily years of individual therapy, and 

in the case of this sample, Emotionally Focused Couple Therapy. Over time, learning the root 

cause of avoidance, and “becoming vulnerable with and holding space for each other” (Sarah) 

was notably beneficial for partners to find a new way of responding and understanding the 

rationale behind a partner’s avoidance symptoms within the relationship. As one participant, 

Janet, explained: 

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I didn’t understand it because there were things she was afraid to talk to me about, and 

[she was] afraid that I would be judgmental about. Once we finally do start talking about 

our past trauma [related to emotional avoidance] and sharing, I had the opposite reaction. 

I’m really genuinely amazed [by my partner], but it takes a really long time because if 

you don’t wanna think about it yourself, you sure as hell don’t wanna talk about it. 

As participant Amy noted, this process was “something that we had to learn and develop through 

a very long course of, of discovery.”  

PTSD: Hypervigilance  

Experience of hypervigilance: A way of being in relationship. When asked about the 

symptom of hypervigilance, participants described the experience of “being watchful, jumpy, on 

guard, and super alert as if something bad is about to happen,” not as a “symptom” like others, 

but more as “a way of being” (Amy). Participants explained, “I live my life like that” (Ryan), 

and, “it’s hard to notice because it’s more” (Amy). Participants also described the experience of 

hypervigilance in their couple relationship as a hyperaware activated state between partners: 

“we’re always ready to rock and roll . . . it’s a real struggle and a constant experience. Like, I 

think we’re always, we’re hyperaware of each other’s physical expressions and definitely the 

verbal expressions” (Evan). 

Participants described two categories of hypervigilance. The first relates to a general state 

of being “very aware of (the surrounding) environment . . . it impacts our sleep and we cannot 

rest, it is very prevalent for us” (Evan). This can also include abrupt experiences of extreme 

fearfulness and an activated sense of threat. As participant Monica detailed, “I can be a very 

logical 46-year-old, and then all of the sudden, I think I’m going to be killed.” These forms of 

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hypervigilance were functionally impairing for participants in terms of their ability to relax and 

move freely in their environment.  

Second, partners recognized the relational component of this individual experience. One 

participant, Matthew, noted: “She’s always waiting for something bad to happen. I understand 

where that comes from with what she’s been through . . . it’s always been that way and it got 

real, real, real, real stressful for her.” However, the burden of symptom management still had an 

impact on participants’ ability to engage with their partners. Participant Erica described the 

impact of symptom burden on the relationship: “I am constantly doing so much to keep myself 

calm and functional that I don’t have a lot of resources left over for [my partner].”  

Experience of hypervigilance: Pervasive fear and distress within the relationship. The 

second and more prominent form of hypervigilance discussed by participants was the experience 

of a pervasive sense of threat related to their intimate relationship, which proved more complex. 

The sense of threat related to participants’ ability to feel secure in their relationships took the 

form of fearing loss, abandonment, or disconnection from their partner; it is “a constant 

evaluation of my relationship. At every moment I am on guard about it” (Erica). This process can 

be mutually triggering because, “we both have the fear of abandonment” (Erica); however, 

participants also emphasized, “we do not do well when we are disconnected” (Monica). Another 

participant described the overwhelming fear of relational disconnection: “I get fearful of (my 

partner) leaving or dying, which I can regulate myself from, but if I feel that he doesn’t trust me, 

I get really afraid” (Brittney). Hypervigilance within the relationship was experienced as a 

symptom on the opposite end of the spectrum from avoidance, and yet it had a similar automatic 

response pattern:  

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As soon as I get a little spark of a thought, I think about it, right. Then I give that energy 

and it kind of grows in my mind and I don’t wanna do it, and I feel bad about doing it. 

And I, like, know I shouldn’t be doing it, but there’s this part of me that, like, does it 

anyway. And then I start trying to connect little dots of things that happen, something to, 

like, almost, like, find the problem when there is no problem in order to ensure that there 

is no danger in a way (Mitchell). 

Partners described the struggle to process and manage their partner’s relational 

hypervigilance: “I mean, I often forget that [hypervigilance] is a way that [my partner] tends to 

experience things. And to me, it seems to manifest as kind of like a controlling tendency . . . 

judgment, criticism, controlling” (Adam). 

Relational impact of hypervigilance: Defensiveness, fear, and being on guard toward 

partners and the relationship. Participants described how their relational hypervigilance led to a 

turning away from their partner and created a relational culture of fear and distrust despite the 

existence of security and no overt relational threats. As one participant, Amy, noted, “I always 

think the worst when it comes to [our relationship] like he’s purposely trying to hurt me. . . . I 

think that’s understood that he’s not . . . But I really believe in that moment.” This fearful and 

relationally hypervigilant state is distressing for couples: “it is disastrous every time” (Ryan). 

Others stated feeling “like everything was [my partner’s] fault” (Mitchell), but knowing this was 

also an automatic protective response inciting fear and panic: “it’s like fake news in a way” 

(Ryan).  

Recognizing the negative impact on their relationship over time and the disconnect from 

their perception and the present process, partners described their struggle to shift from protecting 

themselves and responding to their sense of threat due to the intensity of past trauma:  

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I have a tendency to take any change, any change as an attack. . . . I’m also constantly on 

guard for change. And some changes that I fight in our relationship, I don’t even care 

about . . . [but] I think it’s just because when all those changes happened with my family, 

my entire world is ripped out from under me (Mitchell). 

Partners reported that when their partner experienced them as a threat, this in turn activated their 

own relational hypervigilance, “[I get] hyper on alert because . . . I feel like . . . his brain or 

whatever, doesn’t want him to be happy . . . he always like latches on to see . . . [I’m] not 

trustworthy. So, I get really, like, afraid” (Brittney).  

Participant couples’ inability to let down their guard or think positively in their intimate 

relationships was described as one of the most difficult consequences of CPTSD symptoms due 

to repeated and consistent traumatic experiences in primary attachment relationships throughout 

their lives that brought up issues in the current relationship:  

Because I never knew what to expect. You know, I never knew what was coming around 

the corner and I didn’t have any control of that. So you just get to the point where you 

expect the worst, so you’re not disappointed, but it really changes your thinking and your 

perception. . . . I get really scared (Annette). 

One participant, Ryan, described how a sense of threat related to past trauma can have an 

invasive effect and can impact even the most positive or peaceful relational experiences:  

It could be a 70-degree day. Good food, the kids are behaving, and like everything could 

be right. But then it’s like a drug released into my mind. The fear takes over my body. 

And I want to, like, start looking and searching and doing something to prevent myself 

from being hurt. And it feels very real. . . . I do trust [my partner] . . . but it’s a battle . . . 

[and] it ends up hurting both of us. . . . I want her to know that I do trust her. So at some 

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point, I gotta let go of this defense mechanism. That’s sort of like driving me crazy. It’s 

like my mind knows it’s okay, but my body doesn’t.  

Management and coping with hypervigilance: Mutual awareness and emotional 

connection. Despite the interpersonal and intrapersonal complexity of managing extreme fear 

related to relational hypervigilance, participants had clarity about what helped them manage 

burdensome individual and relational distress related to this experience. For individuals, skills 

related to mindful acceptance and emotional awareness, were key. “Accepting how I’d feel and 

accepting that I’m like afraid or scared” (Ryan) helps participants get out of a panicked or 

defensive state. Another participant noted, “I try to identify the core emotion and recognize if the 

issue is something coming up from the past or in the here and now” (Amy).  

On the relational level, mutual awareness of hypervigilance and its origins directly fed 

into a couples’ ability to redirect and reflect on what is driving fear and conflict within the 

relationship. Often, “[one of us] is really misreading with [the] other, you know? And we know 

that those things come from trauma, the way we respond to things” (Sarah). Participants across 

the sample relayed the progression of healing related to how they learned to respond to each 

other’s sense of threat: “I think what we’ve learned over time is . . . to not try and fix each 

other’s trauma . . . if I’m anxious, [my partner] will say, now . . . ‘I can see you’re anxious.’ 

That’s a difference in the way we would’ve handled it from before, [it’s] just Empathy 101 

[now]” (Gina). These participants further noted that when they would try to “fix” each other’s 

sense of threat, it would “just feel unsatisfied, and not any better or any less anxious” (Gina). 

Another summarized the importance of recognizing genuine vulnerability in her partner to soften 

her sense of threat and facilitate the process of coping with hypervigilance within the 

relationship:  

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I’d say the vulnerability from my partner is what immediately, I guess, puts my guard 

down. And it’s easier to feel loved and safe, and then you’re able to actually hold 

emotional space or compassion for the other one (Sarah). 

Participants additionally recognized that the sense of threat was never just “about the 

content” (Gina) but rather about needing the underlying sense of fear in that moment to be 

understood by their partner. This point was well illustrated by a participant responding to what 

helped her experience lower hypervigilance and arousal related to an attachment wound from her 

spouse:  

I mean, it was good that you, you took responsibility and everything. I mean, that was 

great . . . but that’s not what really won me over, you know, what won me over is that . . . 

you took responsibility, but then you also listened to what [the attachment wound] did to 

me. And that’s when I felt like you were really, really hearing me. . .  Empathizing, and 

like really getting it, like getting what it did to me. Yeah. I mean, that’s where the 

empathy could come from was once he really got it (Rachel). 

PTSD: Reexperiencing. 

Experience of reexperiencing: Reexperiencing was intrusive and impaired cohesion in 

the relationship. Participants described reexperiencing as a pervasive and frustrating symptom 

that required a great deal of mutual awareness to manage individually and jointly. 

Reexperiencing built upon and related heavily to symptoms of avoidance and hypervigilance in 

that reexperiencing posed a serious burden on participants’ lives and relationships, “where 

[reexperiencing an attachment wound from my spouse] was like every five minutes at one point” 

(Brittney). Another participant stated, “I’ve been in therapy for 40 years and at a certain stage, I 

was so constantly flooded with traumatic images that I had to go to the hospital” (Erica). These 

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participants reported how issues in the current relationship activated the wounds from past 

relational traumas. 

Relational reexperiencing. Reexperiencing in this sample was, at times, related to intense 

memory recall in the form of persistent and disturbing nightmares or specific traumatic 

experiences of betrayal, neglect, or abuse playing over again in an intrusive manner. However, it 

was more often described as “not necessarily images” (Kirsten) but rather an unconscious 

experience that replicated “more of the feeling, [or] thoughts” (Adam) that related to 

interpersonally traumatic memories. One participant revealed, “I don’t have images, I have 

crossover experiences that are so similar [to my past], it’s scary, and I feel like I’ve been here 

before and I’m here again” (Mitchell). In this way, participants described how it felt like the 

narrative of the reexperiencing was like a “filter” (Evan) to the present moment in which they 

were responding to something or someone from the past: “[how] it manifests . . . sometimes, my 

responses to something [my partner] is doing are so heightened that I’m, like, this can’t be about 

what’s happening right now. . . . My reaction does not match what’s actually happening in the 

moment” (Kirsten).  

Relational impact of reexperiencing: The unique impact of the couple relationship as 

trauma stimulus. Reexperiencing within the couple relationship started as an internal individual 

signal that in turn impacted partner’s actions and response patterns toward each other. One 

participant, Ryan, relayed the impact of this on his relationship: “[my partner] then feels bad 

because I’m responding to what was and not what is,” to which his spouse responded, “I feel like 

a failure when he does that” (Brittney). Participants relayed that, primarily, this type of response 

was related to perceiving behavioral cues from their partners (i.e., passiveness, anger, avoidance, 

directiveness, or frustration), which spurred on emotional memories of prolonged or repeated 

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traumatic relational experiences. These types of traumatic relational experiences included abuse 

like CSA, and pervasive experiences of bystander inaction, for example:  

When [my partner] is passive, which he often is, because he is historically very 

emotionally avoidant and just likes to keep the peace, it feels like he is my mother, whose 

passiveness was, really, honestly worse than my father’s abuse. I even have a special 

name for [my partner] when he is passive and I call him [that] when I sense that he is 

passive because it makes me feel desperate, like [the past trauma] is happening again 

(Rachel).  

In this way, reexperiencing was a pervasive undercurrent in participants’ lives and relationships, 

a phenomenon of which they were both aware and unaware. Importantly, participants revealed 

how their partner’s noticing or being negatively impacted by the symptom illuminated their 

awareness of its existence and severity: 

We’d be sitting with the kids when they were little and she’d be like, you look like you’re 

miserable and I’m like, what are you talking about? Cause in my head I’m experiencing 

something and I am miserable, but not consciously, right. I’d be like, what are you 

talking about? I’m just sitting (Mitchell).  

Reexperiencing: Management and coping—process of identification and discernment 

between past and the present. Participants detailed their struggle to stay in the present moment 

and recognize reexperiencing when it was happening, and to distinguish between intrusive and 

emergent feelings of past traumatic situations and how those colored their view of their 

relationship and partner in the present. Despite a great deal of work on this symptom, 

participants recognized the ongoing process and how they often managed it by disassociation or 

by covering it up; when this happens, “I just call it getting triggered, but I feel my heart rate and 

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adrenaline, like, pump. . . . I certainly feel it, but I hide it a lot” (Ryan). This symptom required a 

lot of effort, resourcing, and support to manage:  

I will notice images or memories come up that will lead towards disassociation, so I try to 

catch it before it gets there with the array of tools and strategies I’ve developed over the 

years but if I don’t catch it, then I’ll have to go deeper in the continuum of my tools that I 

have for what’s going on (Monica). 

Due to the negative relational impact, others described how they actively made efforts to 

distinguish their partner and their behaviors from the past: “I have to remember that she is not 

my siblings bullying me” (John), or, “just because he is a man does not mean he is like my father 

. . . he is actually so patient” (Gina), or, “we have moved on and we are so much better off now, 

but it takes a lot of work to catch that. My reactiveness (related to reexperiencing) was 

destructive” (Ryan). As participant Brent summarized, “what I’m working on right now is to 

separate myself from the past trauma and recognize what’s happening in the moment. Certain 

things can take me back to a scary place and I have to try to stop myself from going there.” 

The couple process of managing reexperiencing was illuminating, but it was also a road 

of difficulty and ongoing discovery and discernment:  

Because we’ve had so many blowups, we’ve started to recognize and know what’s 

coming next and know that now we have the tools in couple therapy to stop from going 

too far and creating more damage. There are topics we can’t handle on our own, and there 

can be constant landmines (Monica). 

The discovery and management process over time led participants to be very “tuned in” 

(Sarah) to each other’s internal processes, “I feel like we feel each other’s pain now” (Sarah). As 

Evan described: 

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I see it happening, the past coming up for [my partner] in a moment, and I know her so 

well that I can see, even with the way she is walking or how she is moving, I can tell 

what’s happening for her . . . just being there and validating her when that’s happening 

now seems to help (Evan). 

For some, when struggling with reexperiencing, they reported needing to “remove myself 

from the situation” (Erica). Participant Amy noted, “[my partner has] learned that it’s just an 

internal thing that I am processing.” For couples overall, emotional reexperiencing was 

complicated and led to ongoing distress; however, “recognizing that we are really experiencing 

and stopping it before it spirals is the secret I think because from there everything gets out of 

control” (Brent).  

Disorganized sense of self (DSO): Negative self-concept.  

Experience of negative self-concept: Negative and/or defeating internal experiences of 

themselves in relationship to their partners. Participants struggled with the DSO symptom of 

negative self-concept as it related to how they experienced themselves and their relationships. 

This manifested often as an intrusive and deeply felt insecure attachment to partners with beliefs 

of either being unloved, or impending abandonment and rejection: “the way it manifests itself is 

that I think [my partner] doesn’t love me” (Monica), or, “I get afraid that I’m not enough for [my 

partner” (Sarah), or, “despite everything good he does, I have to work past that bad feeling from 

my past, like if I trust him, then I’ll inevitably be screwed over” (Annette). Another stated, “I 

translate my negative beliefs about myself into the marriage a lot” (Ryan). Others described 

recognizing their partner’s struggles with negative self-concept of often feeling like a “failure” 

within the context of their relationship (Brittney). For some participants, this became less 

frequent over time; however, for others, it was again a pervasive experience: “I think every day 

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for me. Every day for me, I’m reassessing . . . it is a constant thing” (Erica). Participant Kirsten 

relayed the combined negative self-concept related to past experiences and ongoing relational 

difficulties:  

There was a period where I felt like a failure and part of it was how we were treating each 

other. And part of it was all that [interpersonal trauma] stuff coming back up for me . . . it 

was starting to bleed in everything in our relationship (Kirsten). 

Due to this pervasive negative internal experience, participants described the impact it 

had on how they relate to themselves and others as they became “overly critical and harsh . . . a 

mistake [from others or myself] shouldn’t have to be the end of the world” (Gina). Participant 

Annette detailed how her negative belief—“I cannot be safe to trust or get close to anyone”—

was a dual experience of distrust and criticism of others and herself:  

I cannot believe I can even trust anyone . . . like, I’ve believed that I’ll never be safe, so 

I’m critical of my environment, [my partner] always says “you’re even too hard on 

yourself.” And, and I am. I have a really high bar and it’s not, it’s not just on other 

people. It’s, you know, I’m harder on myself than even them. And it’s really hard too for 

me to feel like I can like myself, let alone let [my partner] in. 

Relational impact of negative self-concept: Emotional distance and disconnection 

between partners. Participants described struggling with the pervasive Negative Self-Concept 

related to their ability to maintain closeness with others, which correlated to their experiences of 

subconscious avoidance and hypervigilance: “I mean, I feel cut off from people” (Adam), or, “I 

unattached” (Brittney), or, “I can very easily shut off from people” (Evan). Erica illustrated the 

extent of emotional cut-off she experienced due to her negative self-concept and fears that she 

will be rejected and abandoned:  

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I have very serious object permanence problems. . . . I don’t miss people; I don’t 

remember that I miss them until I see them again. Then I’m kind of overwhelmed with a 

sad missing [feeling] . . . it’s just kind of like a shell of protection. . . . I cannot stay 

connected to [my partner]. . . . It’s like I don’t need him, or anyone.  

Relational impact of negative self-concept: Negative relational concept. In terms of the 

larger relational impact, participants described feeling unsafe with their partners. As Mitchell 

relayed to his spouse, “I believe that you were trying to hurt me. Right. And, and that comes 

back to my whole fight or flight thing.” In a comparable way, participants described constantly 

needing to assess and make up for where they perceived themselves to be lacking in their 

relationships, which drove further symptoms of hypervigilance. One participant, Evan, described 

the impact of his negative self-concept on his experience within his life and marriage:  

If I have any sort of feeling that I’m not providing, which usually is [noticing my partner] 

not being happy, or if she makes some sort of comment about me needing to do more, or 

I’m not doing something enough, that is huge because I already feel that way about 

myself. I already feel like I need to do more or I’m not accomplishing something, or I 

could do better, and I’m trying to get better about it, but I rarely see anything that I’ve 

done as being something worthy. Even when I accomplish something, it’s, like, never 

enough [in my mind]. . . . So that is a huge motivator of stress and anxiety that I’m 

constantly battling is being competent, being a good provider.  

And another participant stated: 

I guess it just kind of manifests itself in a way that when I’m cutoff like that, when I’m 

just in my own world and I’m just, like, you know, I’ve struggled to realize my own 

damaging effects on my husband. The things that I do. I think what’s weird—and I kind 

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of came to this conclusion in the last month or two—is that when you have such a low 

opinion of yourself and you think so negatively about yourself, it actually has this effect 

that you don’t even think that anything that you could do could impact anybody 

positively or negatively, because you think so little of yourself. So when I would be 

yelling at [my partner] or whatever, it never crossed my mind that he’s being really hurt 

by me (Monica). 

Relational impact of negative self-concept: A mutually activating cycle. Due to 

participants’ engrained and deeply rooted negative self-concept, partners described how their 

insecurities impacted the way they related to each other: “our words are supercharged, and I 

think we’re reacting a whole lot faster to something that the other one feels like they might be 

coming up short. . . . Trauma definitely has played into those for both of us. . . . That one’s 

tough” (Evan). Participant Erica noted, “I don’t respond well to his negative self-belief. And then 

it kind of spirals or snowballs or something like that. Or, like, cyclical, where he feels shitty 

about himself and then I reinforce it and then he feels shittier.” When their relational insecurity 

cycle was triggered, it often involved misaligned bids for connection that partners experienced as 

reactive and alienating: 

I might really start sending really long rambling emails or texts or ramping things up to 

get some kind of reaction or some kind of proof that he does, in fact, love me, but it ends 

up just pushing him away. So then, that further triggers the whole cycle (Monica). 

Negative self-concept management and coping: Extensive intentional effort and 

resourcing. Managing negative self-concept was a challenging task for participants. As Kirsten 

noted, “I spent four years working on this intensely [in therapy] because I’ve always had the 

limiting beliefs like really strongly.” Participants further noted how external stressors and family 

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transitions worsened these symptoms, and they recognized needing partner support to manage 

them:  

I feel like I had made a lot of progress with my negative beliefs about myself. However, 

it has definitely come back more since having kids and being home. . . . I think I was so 

overwhelmed that I abandoned some of my tools. . . . I would like to incorporate some 

kind of tools that like get us [me and my partner] working together, but I’m not sure what 

that looks like yet (Kirsten).  

Negative self-concept management and coping: Identification, partner awareness, and 

safety to be vulnerable. Despite the ongoing difficulty of a pervasive negative self-concept 

related to their identities and their relationships, participants again identified that individual and 

partner awareness, and the emotional safety that allowed them to be vulnerable with each other, 

were key in their ability to manage this distressing and invasive symptom. Participant Erin 

described how it helped when their partner was able to understand “the reason that I’m acting 

this way is because I’m feeling really insecure,” and this awareness was derived from “having 

talked about this so many times [with my partner] . . . and having awareness of the feeling that’s 

there.”  

Others described the fact that part of the management process involved a combination of 

giving and receiving positive messaging or support from their partners to combat intrusive 

negative beliefs: “I need [positive] feedback to, to feel okay” (Rachel). Participants demonstrated 

that they recognized their partner’s struggles with negative self-concept over time and how that 

impacted the way they interacted within their relationship: “[my partner] will often think that the 

only time I’m happy with her is if she’s doing something good enough or well enough and that if 

she doesn’t do it the way that I would like, that I’d somehow not love her or she’s not 

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worthwhile. And I see that that’s a struggle for her” (Amy). In this way, participant Brent 

emphasized the importance of discerning the combined mechanisms of offering emotional 

support and emotional boundaries that come with positively managing negative self-concept 

within the relationship:  

I noticed that I just used everything I could to make [my partner] feel better. And now, I 

am just trying to support her the best I can but also realizing there’s boundaries between 

what I can do and fix and what I can’t do, and how I can help and how I can’t help. So, I 

just try to support her. . . . I think I just try to do it healthier and less anxious (Brent). 

As noted, negative self-concept was extremely difficult for couples to manage due to the 

deeply rooted negative belief patterns partners already carry that often mutually activate a 

negative belief cycle both within and between partners. However, as with other traumatic stress 

symptoms, emotional awareness, emotional boundaries (recognition of relational limitations), 

emotional safety, and vulnerability were experienced as a relief and had a neutralizing impact on 

relational distress. In terms of negative self-concept, “now, I share it . . . at the end of the day, 

[negative self-concept is] just another series of trauma-related fake news or it’s another series of 

just my mind is like a machine that happens to produce false information because of my history” 

(Ryan).  

DSO: Emotion regulation difficulties. 

Emotion regulation difficulties experience: Reactive cycles of emotional constriction and 

hyperactivation. The DSO symptom of emotional dysregulation was an individual trauma 

symptom that was also strongly linked to partners’ experiences of each other within the context 

of their interpretations, responses, and reactions to each other across time. Due to the intensity of 

prior PTSD and DSO symptoms of avoidance, hypervigilance, reexperiencing, and negative self-

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concept, strong emotions related to the relationship and subsequent emotional eruptions were a 

common experience for couples. In this way, symptoms of fearful reactivity and anger 

(hyperactivation), or emotional avoidance (hypoactivation) such as emotional cutoffs and 

disassociation, played a significant role in couple dynamics and communication. Participants 

described this continuum of hyperactivation and hypoactivation in many ways, noting, “I get 

right in [my partner’s] face a lot, I don’t have a filter” (Erica), and, after an argument, “I don’t 

feel calm for about a week” (Evan). Another described a numbing experience of emotional 

dysregulation and its relational impact: “I do sometimes feel like I will push away my emotions 

and try to be in that numb place because it’s easier for me. And I, I do notice that I will not 

engage with [my partner]” (Amy).  

Relational impact of emotion regulation difficulties: Chronic negative emotional 

experiences between partners. Consistent emotion-regulation difficulties within the relationship 

instilled a negative cycle between partners in which fearful states related to past trauma 

interrupted the current dynamics of the couple relationship. The impact of emotion-regulation 

difficulties in the context of their relationship at times reinforced interpersonal trauma beliefs 

related to negative self-concept and was at times retraumatizing for partners to a severe degree.  

When we split up and things got really bad, it confirmed all of my worst beliefs about 

myself and I, I, it’s hard to say it out loud, and I’ve been working on it, I think I’m 

getting past it, but mainly, I didn’t want to be on this earth anymore (Matthew). 

The impact of distressing dynamics in participant’s relationships was described as 

distressing and included long-term cycles of intense arguments or long periods of disconnection 

that felt like “a civil war between us [that would span across] weeks . . . and we went on for 

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decades like that; [it is] so painful when it’s it going [on], you know, our brain takes it a certain 

direction and it’s, it’s hard. It’s so hard” (Annette). Another participant noted: 

Our cycle of fighting and blow-ups felt like a trap we couldn’t get out of, it was honestly 

really traumatizing to feel like that [constant blow-up’s] was just how it is going to be for 

us, especially after everything we had been through before [in childhood and in our prior 

marriages] (Monica). 

Emotion regulation difficulties: Management and coping—partners discerned and 

expressed needs for individual and co-regulation. Coping with strong emotions with resulting 

reactivity or numbing was difficult for partners to attain; however, they described how combined 

efforts to emotionally regulate both individually and together were key. Participant Amy 

illustrated how she and her partner managed and discerned how to successfully engage this 

process of emotion regulation and co-regulation via connection and emotional vulnerability:  

Sometimes I need to take a break, switch environments, go do something else, which can 

be a struggle [be]cause, as you hear, we have opposite approaches to that. Like, she wants 

to be together [after an argument], and I want to take some space. So I think we’ve, you 

know, learned to kind of make a balance between those two things when each other needs 

it. . . . If I can catch myself doing this or being in this space, I will try to do my best to 

reconnect with [my partner] in a way that feels meaningful, like telling her what’s going 

on with me or like trying to confront, like, what things I’m avoiding. 

Another important finding was the way participants recognized the need for support in 

terms of how they, as a couple, manage emotion-regulation difficulties due to how trauma adds 

intensity to their disagreements or negative emotions:  

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I think we’ve had to recognize is that we’ve had a lot of trauma, right? We both have, and 

it makes things, the intensity of arguments between us very, very strong, so sometimes, I, 

I think it’s okay to hold off and take a break on a certain issue until we can get help. 

That’s why we found our couples therapist, we couldn’t do it alone anymore, and I think 

we need help dealing with these intense emotions we both have, and sometimes we have 

to just table it until we have help (Brent). 

His partner agreed and responded, “Yeah, before it damages us even more, but it is stuff we do 

need to address, and we’re working on it” (Monica).  

DSO: Disturbance in relationships.  

Experience of disturbance in relationships: Trauma was a filter for how partners 

experienced close relationships. The experience of disturbance in relationships was, again, 

extensive and pervasive for each participant couple. When asked about their experience of 

disturbance in relationships, couples shared that it was immense. As one participant noted, “I’m 

sure we could go on for weeks” (Gina).  

Participants relayed painful, complex, or difficult experiences within their relationship, 

which were linked to intrusive symptoms derived from past interpersonal trauma. For instance, 

participant Harry described, “there were [bad] things that happened in [my partner’s] childhood 

that… directly affect our relationship and how we function together because of how she 

experiences constant triggers [being in relationship].”  

Much like hypervigilance was described as “a way of being” and experiencing the world 

for individuals in the sample, the disturbance in relationships symptom was described as a way 

of relating based on past negative relational experiences with primary attachment figures, 

including parents, former partners, siblings, therapists, and even each other. This way of relating 

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mimicked attachment narratives where partners described responding to each other through the 

filter of how they understand close relationships, which instilled defeating patterns that remained 

difficult to overcome. 

I think for me, the trauma that I experience has impacted our relationship, like right from 

the beginning. I mean, I feel like it informed the way that I thought relationships should 

be and what they should look like. And therefore, I think it’s affected the course of our 

relationship and it’s been a focal point in us, like working on being together (Amy). 

Another participant similarly shared his and his partner’s experience of the filter of trauma in 

their relationship of over 40 years:  

I think our, our traumas, um, you know, obviously are the lens we see things through. . . . 

It’s been really difficult, I think for me, to not in certain circumstances assume that [my 

partner] is behaving the way my [abusers] would. . . . It’s very easy for her to see 

something that I do as what her [abuser] would do, right? And for, you know, for those 

[same] motivations. So, I think that’s, that’s how I see it coming into the relationship is, 

um, sort of viewing our partner as, you know, our, our [former] traumatic surroundings. 

As, you know, those [close relationships] are the situations that brought about the trauma 

(John).  

Participants’ experiences of the trauma filter were related to trauma symptom clusters like 

reexperiencing and negative self-concept:  

It [trauma-related disturbance in relationships] adds a filter to whatever is being said or 

the action[s] [between us]. So a good gesture won’t get viewed as a good gesture, or a 

statement will get viewed as a negative statement, or one tiny little bad thing that happens 

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will make the whole day or the whole week seem like it’s all bad. So yeah, I think it 

totally affects every aspect of our relationship negatively (Evan). 

Relational impact of disturbance in relationships: Interpersonal trauma as a 

degenerative, invasive, and harmful third entity in the relationship. The role of trauma was like a 

third person in the relationship that caused havoc. For one particular couple, it led to divorce. 

Though they regretted their divorce and were able to reconcile their relationship, participant Gina 

described the impact of trauma on her relationship:  

I grew up in a really chaotic home and alcoholism and, and narcissism, a lot of bad 

stuff…And I remember saying [to my partner when we were separated] . . . “I feel like 

I’ve been robbed of a lot in my life and you don’t get it back. . . . I feel like I got short-

changed and I feel like,” and I remember saying to [my partner] that day in the driveway, 

“I just don’t think it’s fair that I’m still paying the price for stuff that had nothing to do 

with me.” . . . I feel like it’s—I can almost personify the trauma in my life, like it’s 

baggage for me. And I think it’s a third person in our relationship. It’s a third entity in our 

relationship. . . . I just wanna move on. I just wanna remove that trauma piece from my 

life, and I know I can’t ever, but I can certainly diminish it and manage it. . . . It just 

never goes away. . . . I really had no understanding of it [until the divorce]. I’m 54 years 

old, and I had no understanding of what was happening until this year. 

Participants relayed how the overall impact of their trauma was deeply engrained, and therefore, 

many did not notice the severity of its impact on their relationship until their symptoms 

worsened over time.  

I think [trauma-related difficulties] always have [impacted the relationship] in various 

ways, right. Like from our intimacy to, like, intimacy on both levels. Right. Emotional 

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intimacy versus all of it. Like, we don’t have any of it. [That’s] how we ended up going 

to therapy was all of those, all of those things playing out without us knowing it. . . Cause 

we were literally just fighting, like, over everything . . . that’s how bad it had gotten. And 

I think that it was all of these things we talked about [CPTSD symptoms] playing out and 

we just were so in it, we weren’t conscious of it. (Mitchell) 

Relational impact disturbance in relationships: Polytraumatization and relational layers 

of complexity. Despite the fact that the interviews did not include any discussions around past 

trauma experiences, participants relayed that trauma experienced in differing relational contexts 

each had a unique impact and interaction on their overarching disturbance in relationship 

symptoms. For example, each participant couple, and almost all participants, acknowledged the 

presence of harm or abuse that occurred within the context of their families of origin. However, 

some also shared the additional relational complexity of past trauma experiences in former 

marriages, military experiences, or even in their current relationships, and they relayed how these 

layered traumatic experiences added complexity to ongoing disturbance in relationship 

symptoms within their current relationship: 

We both have experienced some trauma with past marriages, and so that adds another 

element to [relational distress]. . .  I think the fact that it was within the previous bond of 

marriage somehow plays a unique role. I mean, we have trauma that’s different too, but I 

think when you’re talking about marriage and you’re assessing trauma, if trauma happens 

within a marriage prior to a second marriage, then I think it’s probably something special 

or different maybe.  

While the interviews did not address experiences of trauma within participants’ current 

relationships, one participant made explicit the presence of infidelity on his part—an attachment 

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wound within his relationship—and noted an important distinction between trauma within and 

outside of the current relationship. Even though this was an additional trauma for his partner, his 

taking responsibility also contributed to healing.  

I’ll say it again right now, and I do not mind reiterating this. I am and always will be 

responsible for having done that to [my partner]. . . . I have, you know, I caused the 

trauma to [my partner] as far as that trauma is concerned. Right. Other traumas in [my 

partner’s] childhood, I did not cause. But I think it’s extremely important for . . . our 

connectedness, for her to know that I am and always will take responsibility for what I 

did . . . because that didn’t happen in her childhood. It’s a key difference (Harry). 

The unique impact of polytraumatization and what it can look like within a couple 

relationship was well defined by participant Evan, who detailed the way disturbances in his 

relationship that showed up in his marriage were related to diverse layers of trauma that were 

connected to childhood experiences, coupled with military experience and loss. Evan described 

an innate sense of disconnection due to past trauma and relayed how the additional effort on the 

part of his partner was required to mitigate that within their relationship.  

I built this wall based off of childhood exposures but also the military and having several 

combat deployments and coworkers of mine dying and physical and traumatic brain 

injuries. So [my partner] knows that there’s a wall that has gone up. And we have this 

analogy that she has to reach over the wall. Like, there’s a wall that I can’t see her and 

we have that analogy that she’s set up before that she’s reaching over the wall to, to let 

me know that she’s still there but knowing that I can’t see it because there are so many 

layers that go up that are just preprogrammed in me and I’m fighting trauma, but I’m 

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fighting my brain being rewired through military experience to not let anything in. Like, 

do not let anything break or compromise you (Evan). 

Disturbances in relationships: Management and coping—building mutual awareness of 

individual interpersonal trauma symptoms within the relationship. An emergent theme of this 

analysis was the way in which the couple relationship itself served as an emotional space that 

both continually activated partners’ relational distress but also conversely facilitated partners’ 

awareness and ability to recognize the presence of ongoing traumatic stress symptoms as they 

played out within the intimate relationship. Often this was related to participants recognizing the 

negative impact these symptoms had either on their partner, the well-being of their relationship, 

and/or the extent to which their own emotions were exacerbated by their prior understandings of 

relationships (which also related to the reexperiencing symptoms). As Gina noted: 

I think, I remember at one point, [my partner] just, we were on a trip and I was kind of 

freaking out . . . and he just said, . . . “I just don’t want, . . . I just wonder when this is 

ever gonna end.” . . . My anxiety was just so outta control. 

Couples relayed how recognizing the presence and intensity of their emotions and consistent 

conflict in their relationships helped them gain awareness that past trauma and related symptoms 

were becoming harmful: 

A really, really emotional feeling over something that was just a very, very small 

statement. So, that lets me know that there’s something so much deeper going on there 

and it’s not just on her side, there’s stuff that I’m dealing with, that’s making this thing 

escalate (Evan). 

Understanding and identifying trauma while developing mutual support. As with prior 

symptoms, partners’ ability to gain a genuine understanding of their own and their partner’s 

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trauma history and symptoms was a key ingredient to managing disturbances in their 

relationship. This was aided by the resource of therapy (individual and couple) and subsequent 

experiences of emotional safety and mutual support between partners:  

I have to understand his trauma. He has to understand my trauma and we both have to 

understand our own traumas and how it’s affecting us. Yeah, I mean, just thinking about 

that right now, it seems like, you know, everything I’ve worked on either individually or 

that’s been productive in couple therapy is really rooted in the past. It’s, you know, how, 

how, uh, we developed a distorted view and distorted actions, um, and how we’re sort of 

misapplying those to, to now. [For example], I need to really be careful if I’m feeling, if 

what I’m feeling is appropriate for the moment or whether it’s a combination of too much 

of the past (Gina). 

Though each couple within the sample was at a different stage of management and coping, all of 

them reported the importance of awareness of each other’s trauma and how that stimulus plays a 

role in their reactions to each other while also addressing the relational issue as a team:  

We do a better job of just kind of rolling with it [the trauma reactions] and giving each 

other a little more grace. There’s a little more benefit of that in terms of how we’re 

managing it as a couple, we definitely could do a better job, but I think the difference 

now with therapy is I don’t, I probably blame myself more for that more than I blame 

[my partner] if that makes sense. . . . I think that for a long time I blamed you [partner] 

and you are the problem. Instead of it was a we problem. Right. And I feel like for 

myself, I own more of that problem now. And I think that’s because of looking at all 

these trauma issues together. I don’t think we have a solution so far but just a better 

understanding maybe (Mitchell). 

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Participants described how understanding what was happening for their partner 

internally, as it related to past trauma, was what helped them cope by supporting their partner 

and working again as a team to process and heal: 

I think that the biggest thing that helps these issues is that you kind of have to read 

between the lines. It’s not really what’s happening [that’s causing the problem] . . . it’s 

really like the context of past traumatic experiences that both of us have had. And that 

when you’re first in a relationship with somebody, you don’t know that about them. So 

it’s like very hard to connect and be able to like help heal each other . . . [it’s a process 

of] learning how to, like, heal each other a little and, like, learn that like you’re safe and 

you’re okay with that person. And . . . a lot of the things for me don’t happen as often as 

they used to, like, my genuine calm response is because like I’ve learned to trust her, and 

trust myself, and that just has happened with time and [EFT] therapy (Amy).  

The role of hope and importance shifting from individual to relational coping: 

Developing a healing team. Despite the complex trauma histories of this sample, couples 

displayed hope for their relationships and pride for the work they had done in the face of their 

difficulties and struggles as survivors of CPTSD, at times managing severe ongoing 

symptomology. One participant recognized how “being emotionally close and connected with 

[my partner] is critically important to me and to us” (Brent). Another participant articulated:  

Just because we’ve been through all of this horrible stuff doesn’t have to mean we have 

to suffer forever, and that we can’t have what we want in our relationship. I’m going to 

be stubborn about that. We have a great relationship now, but why can’t we have it all 

and work through this stuff together? (Janet). 

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This hope was fostered by individual gains in therapy in terms of self-awareness, 

emotional grounding strategies, and individual trauma processing along with relational gains 

made in EFT couple therapy, where participants described a paradigm shift from functioning in 

opposition to each other to functioning more as an empathetic and cohesive unit, a team standing 

against the trauma:  

I definitely feel like we’re starting, we’re, we’re in, we’re in that, we’re down that road, 

you know, we’re walking in, it’s very slow, but we are walking down the road, you 

know, and we’re going that way towards managing it and, like, and connecting with each 

other during hard times (Rachel). 

Couple therapy was a central component for this sample in terms of their ability to start to 

manage intrusive interpersonal trauma symptomology that was rooted in individual experience 

but that played out within the system of their relationships:  

We both handle difficult, painful situations very differently, and it affected our 

relationship and was really detrimental to our relationship. And so we decided to enter 

couple’s counseling because of that. . . . [As a result], I think that we’ve let each other 

become a part of our healing team. Like both of us are helping each other along with our 

own individual struggles and that’s been really helpful in our relationship (Amy). 

Participants in this sample reported the relevance of couple therapy for their interpersonal 

trauma symptomology overall, recognizing that interpersonal trauma can only be healed and 

addressed within the context of relationships. The couple therapy helped in this goal but required 

a therapist who could stay focused on this process and the uneven healing trajectory from 

difficult traumatic experiences:  

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The therapist is to be committed, to keep focusing on the relationship and how does the 

trauma impact the relationship and then bringing it back to the healing. It—the healing 

happens within the relationship. I mean the therapist helps to facilitate that, but it is about 

[my partner] and I healing and, and being able to be together. So that’s what the therapist 

has to do. And I think that’s hard (Cathy). 

Discussion  

This study used a qualitative approach with a unique sample of ten trauma-exposed couples, 

where one member of the couple met criteria for a CPTSD diagnosis, to explore couple 

experiences of CPTSD symptomology, the impact of these symptoms on their relationships, and 

their approaches to coping. All twenty participants reported repeated interpersonal trauma 

exposures, and nineteen out of the twenty individuals met the criteria for CPTSD as per the ITQ 

(Cloitre et al., 2018), making this a sample of largely dual-trauma couples (Ruhlmann et al., 

2017). In agreement with prior literature, our findings indicate that the depth of the CPTSD 

symptom burden on trauma survivors is severe, and the most distressing relationship difficulties 

are around disturbances in their intimate relationship caused by interpersonal trauma exposure 

(Hyland et al., 2017a; Karatzias et al., 2018b). Additionally, the impact of trauma on the 

relationship was systemic (Oseland et al., 2016), with partners adapting and responding to the 

whole of trauma symptoms experienced within the context of the relationship, often exacerbating 

individual trauma symptoms. Framework analysis for this research question revealed three 

thematic categories within the six CPTSD symptom domains. The findings from the current 

study offer an in-depth contribution to the current empirical understanding of CPTSD and couple 

relationships, providing concentrated attention to the themes of how couples experience, 

understand, and manage CPTSD-specific symptomology within their relationships.  

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Experience of CPTSD within the couple relationship. A unique contribution from this 

analysis was that all participants within the sample experienced their own and/or their partner’s 

symptoms of CPTSD as a common and joint feature of their daily life over the course of years 

and decades. This process led to both ongoing distress and adaptation (Banford Witting & 

Busby, 2019; Oseland et al., 2016). The pervasive experience of CPTSD symptoms served to 

organize their ways of relating and negatively impacted the functioning of their relationship.  

Furthermore, participant couples experienced these symptoms in all of the domains of 

CPTSD, including avoidance, hypervigilance, reexperiencing, emotion regulation difficulties, 

negative self-concept, and disturbances in relationships (Cloitre et al., 2018). These experiences 

of CPTSD were similar to what is described in the literature on PTSD and couples (Nelson Goff 

& Smith, 2005; Oseland et al., 2016). For example, avoidance was a way in which participants 

protected themselves from harm related to past traumatic experiences in relationships (Pearlman 

et al., 2005). However, within this sample, although a symptom like avoidance was a distinct 

symptom, it was related to all other CPTSD symptoms, further exacerbating the remaining 

CPTSD symptoms of hypervigilance, reexperiencing, emotion-regulation difficulties, negative 

self-concept, and disturbances in relationships (Cloitre et al., 2018; Oseland et al., 2016; 

Pearlman et al., 2005).  

Overall, findings from this analysis revealed the relational/systemic nature of symptoms 

for CPTSD survivors (Costa-Ramalho et al., 2017; Pearlman et al., 2005). Participants in this 

sample described avoiding/pulling away from their partners at times, especially during moments 

of emotional closeness/potential emotional closeness in their relationship, due to emotional 

intimacy being the very reminder of past trauma. Because trauma was experienced within the 

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context of close relationships, for this sample, being close in terms of emotional intimacy was 

experienced and interpreted as a trauma stimulus and, therefore, unsafe.  

In this same way, the symptom of hypervigilance was also distinctly distressing for 

couples with CPTSD, as they relayed experiencing their partner as a direct threat and being on 

guard against them related to past traumatic abuse, fear, and loss. This resulted in partners 

viewing and responding to each other and their relationship as the trauma stimulus itself. These 

ways of experiencing each other led partners into cycles of fear, blame, and defensiveness 

against and with each other, destructive relational patterns that led to increased relational distress 

(Smith & Stover, 2016; Stadtmann et al., 2017; 2018). Additionally, findings from this study 

revealed the interwoven experiences survivor couples had with reexperiencing past trauma as an 

intrusive overlay to their current relationship. Reexperiencing not only came in the form of 

images and nightmares, but also equally intrusive and elusive feelings related to prior traumas in 

relationships. This ever-present past impacted survivors’ experiences of the relationship in the 

present, and it maintained diffuse internal distinctions between the unsafe/traumatic past and the 

present moment, which incited additional fear-based reactions between partners (Cassidy & 

Mohr, 2001; Stovall-McClough & Cloitre, 2006; Van der Linde & Edwards, 2013).  

DSO symptomology also posed a unique strain on how survivors experienced their 

relationships (Cloitre, 2015; Cloitre et al., 2020a). For example, emotion-regulation difficulties 

perpetuated negative cycles of emotional hyperactivation and constriction between partners. 

Within the relationship, this took the form of explosiveness and disconnection, which is a 

commonly known element for couples with trauma-related sequala (Dugal et al., 2020; Karris & 

Caldwell, 2015; Makinen & Johnson, 2006). The symptom of negative self-concept was 

particularly difficult for survivor couples due to the inherent defeating beliefs about themselves 

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within their relationships of being unloved, worthless, unsafe, or the feeling that they would 

inevitably fail at their relationship. As outlined by Bryant, this type of negative belief led 

participants to oscillate “between intimate relations and estrangement” (2022, p. 226), further 

distressing the relational system. Indeed, one of the main findings from the current study was 

that couples in the context of CPTSD experienced the world through the lens of CPTSD 

symptoms, which made it difficult for partners to regulate strong emotions and discern between 

the state of their current relationship and intrusive past traumatic experiences. 

In most cases, couples’ distinct experiences of CPTSD symptoms was strained by the 

combined impact of PTSD and DSO symptomology for both partners, but it was also strained by 

the fact that each symptom itself resulted from trauma stimuli within the relationship (e.g., 

emotional closeness and proximity with their partner). Therefore, an important consideration of 

these results within the context of prior studies is that related studies measured traumatic stress 

using measures that did not identify or measure for DSO symptoms. Prior studies identify PTSD, 

and some recognize the presence of interpersonal forms of trauma exposure, most commonly 

childhood sexual abuse (Banford Witting & Busby, 2019; Dalton et al., 2013; Dugal et al., 2020; 

Nasim & Nadan, 2013). Furthermore, due to the higher prevalence rate of CPTSD compared to 

PTSD alone, it is very likely that many participants within those prior samples met the criteria 

for CPTSD.  

Relational impact of ongoing CPTSD symptomology. Findings from the current study 

both supported and elaborated upon prior research with trauma-exposed couples. In terms of 

support, findings from this study indicated how the impact of individual trauma was systemic 

(Nelson Goff & Smith, 2005; Oseland et al., 2016; Stadtmann et al., 2017; 2018). In other words, 

each couple’s functioning was largely defined by how they adapted to the expression of trauma 

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symptomology within the relationship. Similar to what was outlined by Oseland et al. (2016), 

individual functioning, chronic traumatic stress symptoms, predisposing factors, and external 

resources all interacted with couple functioning on the levels of safety and security, emotional 

connection, and conjoint trauma processing.  

Findings from the study showed how the impact of symptoms, though distinct, was also 

like a cascade, in which each symptom had an alienating impact on the relationship in terms of 

cohesion and interpersonal connection. This was rooted in couples’ experiences of each other 

through the lens of past traumatic experiences, which were often triggered in their efforts to get 

close (Karatzias et al., 2018a; Perlman et al., 2005). 

These findings are supported by traumatic stress research, which identifies trauma-related 

diagnoses as those that develop out of fear-conditioning models, which “commence when stimuli 

are paired with an inherently adverse event; subsequent exposure to the conditioned stimuli 

signals threat and results in anxiety” (Bryant, 2022, p. 212). The current study explicated the 

inherent nature of CPTSD-related stimuli within the common human experience of simply 

existing within an intimate relationship. CPTSD symptoms were, in other words, fear-based 

responses to relational interactions with an intimate partner due to the type of trauma individuals 

previously experienced with caretakers, former partners, and other attachment figures.  

A key finding from this study was how participants experienced their relationship 

through the lens, filter, or preprogramming of past repeated interpersonal traumas, with each 

symptom interplaying with their experience of their current relationship (Karatzias et al., 2018a). 

This overlay of relational trauma impacted how the participants in this sample made meaning, 

interpreted, and responded to one another based on their specific history of trauma in 

relationships. However, they also expressed frustration, confusion, and distress related to the 

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constant burden of discerning between fear-based signals related to past trauma and interpreting 

signals in the present moment with their partner (Cassidy & Mohr, 2001; Stovall-McClough & 

Cloitre, 2006). In other words, participants relayed how difficult it was for them to discern 

between their experience of CPTSD symptoms and their present reality, which affected how they 

interpreted the meaning of the moment in their relationships (Baldwin, 2013; Banford Witting & 

Busby, 2019).  

The findings from the current study also illustrated how important close relationships are 

for interpersonal trauma survivors, and how distressing it is when they experience ongoing 

relational crises and disconnection (Greenman & Johnson, 2012). Findings show that relational 

discord between partners stemming from past trauma had a degenerative effect and decreased 

their ability to maintain and benefit from the protective factors of secure and positive intimate 

relationships (Nasim & Nadan, 2013; Nelson Goff et al., 2006). Just as participants expressed 

frustration having to manage intrusive symptoms that they did not cause due to past interpersonal 

trauma, they also expressed how distressing it was for them to be stuck in the negative cycles of 

their current relationship, which had a strong retraumatizing effect on participants (Alexander, 

2012).  

Prior research has indicated that while some individuals with CPTSD struggle to maintain 

their relationships, there is also a high incidence of divorce and separation in this population 

(Hyland et al., 2017a). This was replicated by the current study, with nine participants 

experiencing divorce in their past or current relationship. However, as noted from prior research 

on PTSD samples (Greenman & Johnson, 2012; Karris & Caldwell, 2015), this particular sample 

for this study also worked extremely hard to maintain their current relationships. Despite high 

rates of divorce for CPTSD populations, as Herman (1997) described, those with complex 

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interpersonal trauma histories may try harder than others to preserve or heal their relationship in 

efforts to experience a different and positive outcome in their relationships. This is also in line 

with research on adult attachment, which indicates that individuals may enter a relationship 

hoping to right the wrong that was experienced in previous relationships and stay in a 

relationship in which they are experiencing severe relational distress (Alexander, 2012; Knefel et 

al., 2019; Liotti, 2004; Özcan et al., 2016). The way this impacted the current relationship for 

survivors was an intensity regarding the meaning of interactions within the relationship, 

interpersonal strain due to “ghosts from the past” impacting the current relationship, and partners 

responding to current events or experiences through the filter of the past, which resulted in 

confusion, arguments, disconnection, and emotional distress.  

Management of CPTSD symptoms within the couple relationship. Partners in the 

context of CPTSD in this particular sample were acutely aware of their symptoms, and they had 

the desire, capacity, and resources to address symptoms on a fairly sustained basis. Even so, the 

sheer burden of CPTSD symptoms was striking and was described as a core feature of couples’ 

daily lives that they jointly managed, carrying the load of all the trauma symptoms present within 

the relationship. This finding is supported from prior literature (Hyland et al., 2017a; Karatzias et 

al., 2019a), which highlights the functionally impairing nature of CPTSD, which interplayed 

with couples’ adaptation to trauma (Oseland et al., 2016).  

Ongoing relational distress for this sample was systemic and described as becoming 

unmanageable for both partners over time. Participants described how important their intimate 

relationships were, yet they relayed how the circular impact of CPTSD symptoms led to severe 

relational distress, which in turn further worsened their individual mental health and CPTSD 

symptoms of feeling fearful in the context of their relationship. Due to the depth of impact of 

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CPTSD on their individual and relational well-being, these participants sought out many 

resources to try to alleviate the negative effects of the disorder. It is important to note that this 

was a unique sample, and in the context of the current study, eligible participants met the criteria 

for CPTSD and were actively participating in EFT treatment. Therefore, this sample represented 

a subset of the CPTSD population as a whole, which had both the access to and the means to take 

advantage of relational mental health care.  

What factors helped couples manage CPTSD symptoms. Findings from the current study 

were supported by prior research, which indicates that CPTSD partners are at risk of 

experiencing broken attachment systems or negative cycles within their intimate relationships 

due to past interpersonal traumas and related CPTSD symptoms (Dalton et al., 2013; Dugal et 

al., 2020). This can incite long-term, unstable cycles of trauma and disconnection within the 

relationship; however, based on this sample, intimate relationships also have a strong capacity to 

facilitate a known protective factor for survivors, “the ability to disclose the trauma and to gain 

social acknowledgement of their victim status” (Maercker et al., 2022, p. 67). Within the 

environment of the relationship, participants emphasized the necessity of their partners “getting 

it” in terms of the impact and inner workings of their experience of trauma symptomology. 

Within the context of prior research on adult attachment, this felt sense of emotional attunement 

and responsiveness was powerful in its ability to facilitate individual regulation and co-

regulation in the midst of trauma related relational distress (Alexander, 2012; Fyvie, et al., 2019; 

Greenman & Johnson, 2012; Hazan, & Shaver, 1987; Pearlman et al., 2005). However, for each 

couple, this was an iterative and continuous process that happened within the relationship, and in 

all cases, it was aided by EFT couple therapy and additional external resources like 

psychoeducation, individual trauma therapy, community connection, and somatic interventions. 

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This finding further supports the expansive literature that suggests a multipronged approach to 

CPTSD intervention (Bryant, 2022; Cloitre et al., 2011; 2020a; 2020b; De Jongh et al., 2016;  

Gerge, 2020; Karatzias et al., 2019b; Lonergan, 2014; Matheson & Weightman, 2020; Monson et 

al., 2022; Pearlman et al., 2005; Van der Linde & Edwards, 2013).  

Trauma impact awareness and mutual discovery phase. Because the majority of 

participants in this sample (n=19) met the criteria for CPTSD, and all had exposures to 

interpersonal trauma, this sample described a discovery phase over the course of their 

relationship in which they uncovered the impact/presence of trauma symptoms within the 

relationship. Though this was a key ingredient to managing symptoms, it was also an extremely 

difficult process due to the lack of inherent safety this population experienced in relationships 

(Banford Witting & Busby, 2019; Liotti, 2004; Stovall-McClough & Cloitre, 2006). Therefore, 

interventions and psychoeducation that supported partners’ ability to develop a common 

language and context for their symptoms was key to the development of their emotional 

awareness related to CPTSD symptomology. A depth of awareness regarding the origins and 

inner workings of trauma symptoms supported co-mentalization and co-regulation between 

partners (Greenman & Johnson, 2012; Hazan, & Shaver, 1987; Pearlman et al., 2005). Porges & 

Furman, 2011; Ruhlmann et al., 2017; Stadtmann et al., 2017; 2018), which in turn enabled them 

to differentiate between the past trauma and the current moment. The ability to identify and even 

start to distinguish distinctions and differences between the past and present was extremely 

valuable and empowering for individuals and couples. This is supported by prior research, which 

has identified the importance of a mindful attunement and a ‘here and now orientation’ in trauma 

intervention to support clients’ ability to stabilize and experience safety via intrapersonal and 

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interpersonal signals of safety (Chouliara et al., 2020; Cloitre et al., 2011; Porges, 2009; 

Stadtmann et al., 2017; 2018).  

Co-regulation, management, and vulnerability. Findings revealed another key ingredient 

to management, which was an internal shift within the relationship toward vulnerability between 

partners (Nasim & Nadan, 2013). Emotional transparency and vulnerability were extremely 

difficult for this population due to individual trauma symptoms that incited emotional avoidance 

and fear-based responses within their intimate relationships. Adult attachment literature has 

identified the way in which past negative experiences in primary relationships can create an 

ongoing insecure (or fear-based) attachment style in adults, which was the case for this sample 

(Fyvie, et al., 2019; Greenman & Johnson, 2012; Hazan, & Shaver, 1987; Pearlman et al., 2005). 

However, as couples experienced positive, and emotionally safe, vulnerable interactions over 

time, this facilitated lower negative arousal toward the relationship and their partner that 

reflected a more securely attached relationship (Alexander, 2012; Hazan, & Shaver, 1987; 

Pearlman et al., 2005).). In line with polyvagal theory (Porges, 2009; Porges & Furman, 2011), 

partners made constant appraisals regarding the safety of connection and vulnerability. Empathy 

was a key component to the positive management of these symptoms. Across the sample and 

across symptoms, participants described how empathy from their partners surrounding their 

difficult symptoms was powerful, and how it stood in juxtaposition to experiences of their 

partners trying to “fix” or even “change” the symptom (Nasim & Nadan, 2013; Stadtmann et al., 

2017; 2018). The participants in this sample indicated that partners’ attempts to get involved 

with their symptoms to either fix or change what was happening for them was not only 

ineffective, but it further exacerbated symptoms and put strain on the relationship.  

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Finally, the findings from this study indicated the value of couple relationships for 

CPTSD survivors. Positive close relationships are a core protective factor mediating against 

negative outcomes across human experience (Baucom et al., 1998; 2012; 2014; Benjet et al., 

2016). As partners gained tools to effectively manage symptoms, namely through co-regulation, 

they in turn experienced protection from their intimate relationship, allowing them to access an 

emotional state of calm, reflecting a more secure attachment style (Pearlman et al., 2005). 

Participants directly attributed this sense of calm to experiencing empathy and being understood, 

loved, and accepted by their partners despite their struggles (Paivio & Laurent, 2001). Dual 

trauma couples in this sample were able to offer a depth of empathy and understanding, which 

was extremely positive for partners in the context of interpersonal trauma (Ruhlmann et al., 

2017; 2019). This also included acting as each other’s advocate and protector from other unsafe 

relationships in their lives (i.e., former abusers, many within their families of origin). In this 

sense, the intensity of their love and bond, despite symptoms, was very strong; however, they all 

described a way in which the symptoms led to ongoing crises in their relationship that would 

have furthered their interpersonal distress without intervention (see chapter 5).  

Though the participants in this sample reported ongoing CPTSD symptoms, they also 

described how the growing quality of their intimate relationship served as a protective factor 

mediating against symptom severity (Vaillancourt-Morel et al., 2019; Volgin & Bates, 2016). In 

her seminal work, Herman (1997) recognized that healing for interpersonal trauma populations 

must happen in the context of relationships. Therefore, a depth of understanding surrounding 

CPTSD symptoms and their inner workings within close relationships was essential for this 

sample (Chouliara et al., 2020 Pearlman et al., 2005; Stadtmann et al., 2017; 2018; Van der 

Linde & Edwards, 2013). The findings from the current study offer strong support for a 

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relational intervention framework for CPTSD conceptualization and intervention (Bryant, 2022; 

De Jongh et al., 2016; Chouliara et al., 2020; Cloitre et al., 2011; 2020a; 2020b; Coleman et al., 

2021; Forbes et al., 2020; Forde & Duvvury, 2021; Gerge, 2020; Karatzias et al., 2019b; 

Lonergan, 2014; Matheson & Weightman, 2020; Monson et al., 2022). 

Clinical implications. Earlier studies have explored couples’ adaptations to prior 

traumatic stress exposure within the context of their current relationship and have provided key 

clinical guidelines for trauma-exposed couples, including the importance of establishing safety, 

and emotional attunement (Blow et al., 2020; Nelson Goff, et al., 2005; 2006; Oseland et al., 

2016). Empirical research has only begun to explore the multifaceted individual experience of 

CPTSD (Forde & Duvvury, 2021; Stadtmann et al., 2017; 2018; Van der Linde & Edwards, 

2013). Due to the innate relational distinction in trauma type associated with CPTSD, and the 

severity/relational nature of the diagnosis, the current study sought to examine the experience of 

couples in the context of CPTSD as a distinct diagnosis. The aim of this research was to uncover 

the inner workings of CPTSD symptomology within intimate relationships and thus promote a 

greater understanding of interpersonal trauma survivors’ therapeutic needs in the context of their 

relationships, in turn better informing relational interventions for this intrinsically relational 

diagnosis.  

The traumatology and systemic family therapy fields have each identified the need to 

further determine the complex relational underpinnings of interpersonal trauma on CPTSD 

populations to support future intervention research (Bryant, 2022; Chouliara, et al., 2020; Dalton 

et al., 2013; De Jongh et al., 2016; Pearlman et al., 2005). In light of prior research, the findings 

from the current study have some important clinical and empirical implications. A key clinical 

implication of this research is the added support for the importance of the systemic and 

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attachment-based lens for CPTSD treatment (Coleman et al., 2021; Fyvie, et al., 2019; Greenman 

& Johnson, 2012; Hazan, & Shaver, 1987; Pearlman et al., 2005). Further, due to the importance 

of intimate partner attachment bonds to human functioning and well-being, especially for those 

who are vulnerable and who have been victimized by prior attachment figures, it appears to be of 

upmost importance to support couples’ ability to mutually disclose and acknowledge trauma 

experiences and ongoing symptoms to promote well-being. Although the extent of disclosure is 

not clear, couples in this study reported that some disclosure and vulnerability created closeness 

and cohesion in their relationships. Findings from the current study indicate that couples manage 

the load of CPTSD together. Therefore, as recognized by prior research (Oseland et al., 2016), 

systemic interventions can help couples jointly target CPTSD-specific symptomology and aid in 

the co-management of symptoms to avoid retraumatization through unhelpful relationship 

dynamics (Alexander, 2012; Dugal et al., 2020; Gerge, 2020).  

Due to the retraumatizing nature of chronic relational distress for CPTSD populations, 

early intervention—and early attachment-based systemic intervention, specifically—is a key 

consideration to prevent the worsening of symptoms and years of unnecessary distress. CPTSD 

is high in treatment-seeking populations, and this sample exemplified the degree to which 

individuals with CPTSD are seeking care. Systemic conceptualization and systemic intervention 

are essential ingredients for the effective treatment of interpersonal trauma survivors, especially 

those living in partnered committed relationships. This particular sample reported decades of 

cumulative therapy, including individual and couple therapy; however, their distress was still 

high in terms of CPTSD-related symptomology. Furthermore, the couples in this sample reported 

only experiencing relief in their relational distress after participating in EFT couples’ treatment 

(see chapter 5). Therefore, future research must address the relational nature of CPTSD to further 

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determine key components and mechanisms of change for CPTSD intervention using relationally 

based and trauma-informed treatment modalities. Finally, due to the complexity and inherent 

relational vulnerability of CPTSD, clinicians should seek ongoing training and supervision to 

develop competencies in working with interpersonal trauma survivors.  

Limitations. There were several limitations for this study that impact the generalizability 

of the results. First, this sample was representative of a subgroup of those who met the diagnostic 

criteria of CPTSD in that they were all in long-term committed relationships, they all had high 

levels of education and SES, and they all had access to many resources, including various forms 

of long-term therapy, to help them manage symptoms individually and as a couple. Despite 

recruitment efforts, this sample was also fairly homogeneous in terms of race and ethnicity. This 

sample was highly committed to their current intimate relationship, which is not always the case 

for those with CPTSD. Therefore, these results reflect the experience of highly committed 

CPTSD couples. Additionally, CPTSD has a high prevalence in treatment-seeking populations; 

however, so does drop out for those with interpersonal trauma (Hyland et al., 2017), so this 

sample is representative of a subgroup of the CPTSD population who successfully utilized 

treatment.  

Future studies should include more diverse samples of CPTSD survivors in terms of race 

and ethnicity, gender identity, and non-Western cultures. Additionally, this study focused on 

couples in the context of CPTSD who had received effective relational treatment. Therefore, in 

order to understand the experiences of other populations, future studies should include couples 

who chose to end their relationships due to CPTSD symptoms and those couples who dropped 

out of therapy. Finally, future studies would benefit from exploring how varying trauma types 

impact couple functioning.  

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Conclusion 

A unique characteristic of this study was that it employed a qualitative approach to 

privilege survivors’ and their partners’ perspectives concerning how this diagnosis of CPTSD 

impacts their relationship and their journey toward finding ways to cope. CPTSD symptoms are 

an ongoing relational issue that couples co-experience and manage together. CPTSD 

interventions must factor into the core relational aspects of survivors’ experience, both in 

conceptualization and intervention. The findings from the current study indicate the importance 

of disentangling past trauma from the current experience of the relationships for interpersonal 

trauma survivors. Findings indicate the importance of bolstering the protective nature of close 

relationships and mediating the worsening of interpersonal trauma symptoms by stabilizing 

couples and strengthening bonds in the couple relationship.  

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CHAPTER 5: STUDY TWO—COUPLES’ EXPERIENCES OF EMOTIONALLY 

FOCUSED THERAPY IN THE CONTEXT OF CPTSD SYMPTOMOLOGY 

Abstract  

Complex Post Traumatic Stress Disorder (CPTSD) is the most prevalent form of a 

traumatic stress diagnosis. It is also the most functionally impairing. Consequently, it is a leading 

concern among mental health professionals. CPTSD—which can result from physical, sexual, 

mental, or emotional abuse—includes PTSD symptoms and an additional cluster of symptoms 

that indicate a Disorganized Sense of Self (DSO), including pervasive disturbances in 

relationships. The symptoms of CPTSD shave been shown to have a negative impact on intimate 

relationships. Emotionally Focused Therapy (EFT) with couples has been identified as a 

promising attachment-based relational intervention for populations diagnosed with CPTSD. In 

this qualitative study, couples who were involved with EFT treatment, and who had at least one 

partner who met the criteria for CPTSD, were recruited to participate in a joint, semi-structured 

interview. Framework analysis was used to analyze the data, examining couples’ experiences of 

EFT in the context of CPTSD symptoms and analyzing their perspectives concerning EFT’s 

acceptability for the treatment of trauma-related distress within their relationships. Findings for 

this study overarchingly indicated couples’ perceptions of the benefits of EFT in treating their 

relational distress in the context of CPTSD symptomology. Themes from this study relay the 

value of key components of EFT such as the attachment frame, cycle tracking, emotional 

attunement, and present process for this population. Findings also revealed important 

considerations for EFT therapists in treating couples in the context of CPTSD.  The conclusion 

discusses the study’s implications for further research and clinical recommendations.  

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Introduction  

Complex Post Traumatic Stress Disorder (CPTSD) has been identified as a primary focus 

for developing interventions due to the current lack of evidence-based interventions for this long-

known (Cloitre et al., 2011; Herman, 1997) yet newly defined disorder (Cloitre et al., 2018; 

Hyland 2017a). The current standard of care for trauma intervention relies most heavily on 

addressing the three clusters of PTSD symptomology using exposure-based, memory-processing, 

or trauma-informed cognitive behavioral interventions (De Jongh et al., 2016; Karatzias et al., 

2019). However, due to the complexity of interpersonal trauma exposure involved in CPTSD, it 

is a more severe disorder, a more complex form of trauma that is both more prevalent and 

functionally impairing than PTSD alone (Hyland et al., 2017a; 2017b). Empirical evidence 

indicates that traditional interventions for traumatic stress have proven ineffective for CPTSD, 

with minimal, if any, long-term outcomes. This has left millions without long-term effective care 

(Dorsey et al., 2016; Matheson & Weightman, 2020). Empirical studies also suggest that current 

traumatic stress interventions are ineffective due to their inability to address CPTSD and the 

specific disorganized sense of self (DSO) symptomology, either in addition to or prior to 

targeting the PTSD symptoms (Bryant, 2022; Chouliara et al., 2020; Cloitre et al., 2011; 2020a; 

2020b; De Jongh et al., 2016). Due to the relational nature of CPTSD-induced trauma (e.g.,, 

adverse childhood experiences [ACES], sexual abuse, domestic violence) (Herman, 1997; 

Hyland et al., 2017a; 2017b; 2020), empirical literature supports the central importance of 

addressing and integrating relational components into CPTSD interventions (Bryant, 2022; 

Chouliara et al., 2020; Cloitre et al., 2011; 2020a; 2020b; Coleman et al., 2021; De Jongh et al., 

2016; Forbes et al., 2020; Forde & Duvvury, 2021; Gerge, 2020; Karatzias et al., 2019b; 

Lonergan, 2014; Matheson & Weightman, 2020; Monson et al., 2022).  

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CPTSD interventions. After many years of study, CPTSD was designated in 2018 as a 

distinct disorder in the International Classification of Diseases, 11th edition (ICD-11; Cloitre et 

al., 2018). The diagnostic criteria for CPTSD includes a combined presentation of both PTSD 

and DSO symptomology, along with indications for functional impairment that are related to 

each subset of symptoms (Cloitre et al., 2018; Hyland et al., 2017b). A critical concern 

supporting the designation of CPTSD as a distinct disorder from PTSD stemmed from fact that 

no evidence-based interventions effectively or sustainably address the full spectrum of CPTSD 

symptoms. Most notably, current trauma interventions struggle to address the complex relational 

components of CPTSD, including the nature in which interpersonal relationships serve as an 

ongoing and distressing trauma stimulus, resulting in chronic disturbances in relationships for 

those with CPTSD.  

In terms of evidence-based care for sequela related to CPTSD, Mahoney et al. conducted 

a meta-analysis and reviewed outcomes and treatment effects for populations with similar 

symptoms and trauma types linked to CPTSD (2019). The review included studies that address 

sequela related to CPTSD, which were deemed rigorous in terms of methodology and approach 

(Mahoney et al., 2019). This review found that, compared to usual care, trauma memory 

processing was effective in reducing trauma symptoms, which shows promise for similar studies 

with CPTSD populations. However, it was inconclusive as to whether other aspects of trauma 

interventions, such as emotion regulation skills training and psychoeducation, were and effective 

form of treatment (Mahoney et al., 2019). Importantly, this analysis highlighted the preliminary 

effectiveness of group interventions that actively incorporate social support, and it advocated for 

the need for further scientific inquiry and the expansion of relational forms of care for CPTSD 

treatment.  

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A more recent study by Webb et al. (2022) administered the International Trauma 

Questionnaire (ITQ) to a female population with a prior diagnosis of emotionally unstable 

personality disorder (EUPD), a common comorbidity for populations with repeated experiences 

of interpersonal trauma, and explored the associations of CPTSD symptoms to functional 

impairment. The results from this study revealed that “a persistent sense of threat and 

interpersonal difficulties stemming from traumatic experiences may reflect particularly crucial 

targets in interventions for individuals with EUPD and complex trauma needs” (Webb et al., 

2022, p. 1). This suggests that intervening in interpersonal relationships—when it is possible—

may be a key intervention approach with this population. 

Couple interventions for trauma. Interventions with couples have been shown to help 

in the treatment of individual mental health disorders, including anxiety, depression, eating 

disorders, schizophrenia, obsessive compulsive disorders, post-traumatic stress, and substance 

abuse (Baucom et al., 2014; Doss et al., 2022; McWey, 2022; Fischer et al., 2016, Wittenborn & 

Holtrop, 2022), for example, demonstrated that interventions with couples, in addition to being 

as effective as individual therapy, could also help increase relationship functioning. In a 

randomized control trial conducted by Wittenborn et al. (2018), Emotionally Focused Therapy, a 

popular attachment-based couples’ intervention, was significantly more effective than usual care 

in helping to treat individual depression and relationship satisfaction. In terms of the treatment of 

traumatic stress, Suomi et al. found that couple therapy effectively lowered trauma symptoms for 

individuals with PTSD (2019).  

Including intimate partners in treatment acknowledges that clients and their symptoms 

are not operating in isolation but instead exist in a system (Kozlowska, 2020; McWey, 2022). 

When couple therapy is used for individual disorders, it allows clinicians to use the intimate 

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relationship as a mechanism of change by developing a secure foundation and mutual support so 

that partners can explore the mental health concern and related challenges by creating new 

interaction patterns, processing previous wounds, and learning new mental and emotional 

skillsets (McRae et al., 2014). However, the empirical and clinical literature also indicates that 

“clients’ trauma experiences can pose considerable barriers to couple therapy” (Linder et al., 

2022b, p. 21). Therefore, further areas of research regarding the use of couple therapy for 

individual disorders would include its usefulness for specific individual disorders like CPTSD 

and the determination of the most effective mechanisms of change (Baucom et al., 2014; Costa-

Ramalho et al., 2017; Johnson, 2003).  

CATS Model. The couple adaptation to traumatic stress (CATS) model was first 

developed and then expanded in two manuscripts, (Nelson Goff & Smith, 2005; Oseland et al., 

2016), which explored the systemic effects and mechanisms of trauma symptomology on 

interpersonal functioning within couple relationships. The first paper sought to expand prior 

literature, which identified the negative impact trauma has on couple relationship functioning in 

addition to exploring the mechanisms of secondary trauma within these relationships (Nelson 

Goff & Smith, 2005). The authors conclude that the quality of components involving individual 

factors (i.e., individual stress), predisposing factors such as external resources and support, and 

couple functioning all interact with and influence how couples adapt to traumatic stress 

symptomology within the relationship (Nelson Goff & Smith, 2005). Importantly, predisposing 

factors related to chronic stress, attachment (emotional connection), symptom identification, and 

empathy within and between partners were core components which influenced couples’ 

adaptation to and coping with traumatic stress either positive or negatively (Nelson Goff & 

Smith, 2005). For example, couples who had high rates of chronic stress, low symptom 

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identification, low empathy within the relationship adapted negatively to traumatic stress 

symptoms. Whereas, couples who experienced protective factors of emotional connection, lower 

chronic stress, and mutual empathy surrounding symptoms could experience their relationships 

as a source of healing rather than a source of additional stress (Nelson Goff & Smith, 2005).  

The second manuscript by Oseland and colleagues (2016) provided a pragmatic 

framework for clinicians working with trauma exposed couples.  This framework identified key 

clinical components with this population, which supported an interpersonal or systemic approach 

to trauma intervention (Cloitre et al., 2011) and highlighted the central importance of 

establishing, safety and stability, traumatic processing, and emotional connection (Oseland et al., 

2016).  

Emotionally focused couple therapy. Numerous studies within the field of systemic 

family therapy field have identified the importance of systemic conceptualization and 

intervention for traumatic stress response (MacIntosh & Whiffen, 2005; MacIntosh & Johnson, 

2008; MacIntosh, 2018; Monson et al., 2022). Additionally, a systemic approach is particularly 

effective for individuals with accumulated interpersonal trauma histories and ongoing distress in 

relationships, as captured by CPTSD (MacIntosh, 2018; Roundy, 2017; Suomi et al., 2019; 

Vaillancourt-Morel et al., 2019). Research in this area has involved EFT, and it has produced 

early, promising evidence (Dalton et al., 2013; Johnson, 2019; Roundy, 2017).  

EFT core components. EFT is an intervention that is attachment-based and experiential. 

It uses current process and emotional enactments in the creation of new emotional connections 

and patterns between members of a couple (Johnson, 2003; 2019). Previous research on EFT has 

demonstrated that mechanisms of change depend on this experiential process and the way it 

allows partners to develop emotional attunement and safe, secure attachments with one another 

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(Wiebe & Johnson, 2016). More specifically, the mechanisms of EFT work to restructure couple 

interactions through three change events, which involve de-escalation/stabilization, withdrawer 

re-engagement, and pursuer-softening (Johnson, 2019). The de-escalation/stabilization stage 

explicates partners awareness and experience of their negative relational cycle, which is based on 

attachment related fears and related primary emotions within the relationship (e.g., fear of 

abandonment, neglect, or control). Partners’ experiences of connecting to their own and each 

other’s core attachment narratives promotes co-regulation through a deepened emotional 

awareness (between self and other), emotional flexibility, and bonding (Hazan & Shaver, 1987; 

Porges, 2009). In the second stage of EFT, the withdrawer re-engagement and pursuer softening 

events promote a secure attachment, which consists of deepening emotional accessibly and 

responsiveness between partners (Johnson, 2019). Emotional attunement and subsequent co-

regulation between partners further promote emotional safety and secure attachment (Hazan & 

Shaver, 1987) as well as individual emotion regulation skills (McRae, et al., 2014). Each of the 

stages of EFT are also critically supported by the underlying approach of the model, which is 

attachment-based and experiential in that the intervention redirects couples to the present 

moment to process their emotions instead of the content of couple conflict (Johnson, 2019). The 

goal of EFT is to successfully establish a secure attachment bond between partners and 

restructure the negative interaction cycle. This shift allows couples to experience each other and 

the relationship as safe and responsive to their emotional needs, which is especially crucial for 

populations who have insecure attachment styles and histories of interpersonal trauma (Dalton et 

al., 2013; MacIntosh & Johnson, 2008; Welch et al., 2019).  

Empirical support for EFT and trauma. In terms of EFT as a clinical intervention for 

trauma populations, the majority of the empirical and clinical support we have for utilizing EFT 

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as treatment for PTSD/CPTSD involves case studies (Johnson, 2002; MacIntosh & Johnson, 

2008), theoretical discussions about EFT’s potential efficacy for CPTSD (Johnson, 2002; 

Roundy, 2017), and Dalton et al.’s randomized clinical trial with adult survivors of childhood 

sexual abuse (Dalton et al. 2013). All this research has foregrounded the viewpoints of clinicians 

who work with clients with severe interpersonal trauma, clients who are engaging with 

“relationship trauma and terminal relational distress” and who have experienced a significant 

change from EFT (Johnson, 2002, p. 65). The theorizing of EFT’s usefulness for interpersonal 

trauma survivors has been particularly noteworthy; multiple manuscripts offer detailed 

demonstrations concerning the ways that EFT’s attachment-based mechanisms address the 

insecure attachment and resulting mental health symptomology that commonly result from 

severe interpersonal trauma (Roundy, 2017; Wiebe & Johnson, 2016; Wiebe et al., 2017). Some 

of this research has involved populations with a wide range of traumas (Dalton et al., 2013; 

Macintosh, 2014), but these studies did not involve a CPTSD-specific population. Therefore, in 

order to understand whether EFT is actually a good fit for the distinct diagnosis of CPTSD, more 

evidence is necessary. 

There are promising studies that demonstrate how it may be useful to use EFT 

interventions with populations that are affected by CPTSD. This research, however, also makes 

clear that the symptoms of CPTSD can make a full engagement in the EFT process difficult for 

survivors (MacIntosh & Johnson, 2008). Consequently, other studies have proposed some other 

adaptations to EFT for populations suffering for CPTSD. These include a longer duration of 

treatment, increased assessment, and integration with other trauma therapies such as EMDR 

(Johnson, 2002; Linder et al., 2022a; 2022b). All of these recommendations, however, 

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foreground a clinical perspective, and there still have not been any studies concerning how 

individuals with CPTSD experience EFT interventions.  

Present Study  

The present study seeks to explore clients’ experiences of EFT in the context of CPTSD 

symptomology as a way to expand our current understanding of CPTSD intervention and the role 

of key components in treatment. This study was guided by the following research question: How 

do individuals with CPTSD and their partners experience EFT and perceive the acceptability of 

EFT in treating their relationship difficulties; in addition, what do they describe as especially 

beneficial or difficult about participating in EFT?  

Method 

Procedures. 

Recruitment. Before this study was conducted, all procedures were approved by the 

Michigan State University Internal Review Board. The recruitment of subjects for this study 

occurred throughout two stages during an open recruitment period between November 2021 and 

June 2022. The first stage involved a community-engaged approach that used purposive, 

convenience, and snowball methodology to access advanced EFT therapists as recruitment 

“liaisons” and “gatekeepers” to clinical participant couples for the study (Archibald & Munce, 

2015, p. 35). These liaisons were essential as they provided access to a population of couples in 

the context of EFT and CPTSD, which would otherwise be extremely difficult to reach. If a 

therapist’s training level and self-reported fidelity to the EFT model with couple clients were 

unknown, they were asked to complete an EFT therapist eligibility survey using Qualtrics survey 

software (Appendix E). The next stage of the recruitment process involved purposive sampling. 

The eligible therapist liaisons were asked to share the study flyer with their couple clients 

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(APPENDIX A), which included requirements for the study and a link to the couple screening 

Qualtrics survey (Appendix C). The recruitment process spanned an 8-month period and was 

completed once the study included 10 couples and once the qualitative data indicated saturation.  

Screening and eligibility. This study involved multiple layers of screening. First, 

therapists had to indicate their level of EFT training and self-report how closely they adhere to 

the EFT model in their work with couple clients (Appendix E). Participating recruitment 

therapists had completed advanced EFT training; 24 had completed through core skills 3, and 4 

had completed certification in EFT. The aforementioned trainings in EFT require a master’s 

degree in a counseling related field, a four-day training in EFT, which is the EFT externship 

taught by a certified Eft trainer. Core skills in EFT requires four 12 hour trainings by an EFT 

trainer from core skills 1 through 4. (Second, the screening of potential couple clients for the 

study included five key eligibility considerations: (1) the couples had to be in a committed 

relationship with one another for at least six months, and they both had to be over 18 years of 

age, (2) to ensure that participating couples could speak sufficiently to their experiences with 

EFT, they had to actively be engaged in treatment with an EFT therapist for at least eight weeks 

prior to the commencement of their participation in the study, (3) each participating couple had 

to individually fill out  screening surveys with matching names and email addresses including 

(their own and their partner’s), as well as matching locations, EFT therapists, and duration of 

treatment, (4) one or both partners had to meet the criteria for a CPTSD diagnosis as defined by 

the ITQ, and (5) both partners had to consent to participation in a joint interview. Once 

participating couples successfully passed the initial screening, they completed a second survey 

(Appendix C) that asked for their demographic background information and a final confirmation, 

allowing the study’s author to send the couple their informed consent form over email (Appendix 

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B) forms and to schedule a two-hour interview. When couples did not meet all of these criteria, 

they were withdrawn from consideration for this study. Official enrollment in the study began 

once participants filled out the informed consent form.  

Participants. A final count of 10 couples, or 20 individuals, participated in this study. A 

majority of participants (90%) identified as White/Caucasian (n=18) and 10% identified as 

Hispanic or Latino (n=2). In terms of gender identification, 40% identified as male (n=8) and 

60% identified as female (n=12). The participants indicated ages within the survey options 

between 25–34 and 65+ years old, indicating a wide range in age across the sample. A majority 

of the participants (80%) were married (n=16), while 10% were in a dating relationship (n=2) 

and another 10% were in a dating relationship after their divorce (n=2). The average relationship 

length was 17 years, and relationship lengths ranged from 3 to 42 years. A majority of 

participants (95%) had children within the span of their relationship. Participants’ sexual 

orientation varied, with 75% identifying as heterosexual (n=15), 10% identifying as queer (n=2), 

5% as lesbian, (n=1), 5% as bisexual (n=1), and 5% as pansexual (n=1). Overall, this sample 

experienced a high SES, with the majority of participants (65%) reporting a gross income of 

$100,000 or higher (n=13), 20% reporting $80,000–$99,000 (n=4), 10% reporting $60,000–

$79,000 (n=2), and 5% reporting $40,000–$59,000 (n=1). Participants’ education also varied, 

with 5% having earned a doctorate degree (n=1), 45% having completed a graduate or master’s 

degree (n=9), 40% having earned a bachelor’s degree (n=8), 5% having completed some college 

(n=1), and 5% having completed technical school (n=1).  

Within this study, almost the entire sample met the criteria for CPTSD (n=19) based on 

the scores from the self-report ITQ in their screening, which indicated an average score of 38 

(range=22–61). These scores represent a moderate to high level of symptom severity with a 

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minimum cut of score of 16 and a maximum score of 72 to meet the CPTSD diagnosis. 

Importantly, most couple scores were somewhat similar differing by an average of 10 points 

between partners (range 2-22), which indicated that partners within this study overarching 

partnered with someone who not only also had CPTSD, but experienced symptoms close to the 

same level of severity. 

Measures. 

Demographics. Participants were asked to complete a standard demographic screening 

that asked questions about age, gender, race and ethnicity, SES, relationship status, length of 

time in their current relationship, number of children, and their length of time in EFT (Appendix, 

D).  

International Trauma Questionnaire. The International Trauma Questionnaire (ITQ) 

(Appendix F) was developed for the eleventh edition of the International Classification of 

Diseases. Currently, it is the only valid and reliable measure for differentiating between PTSD 

and CPTSD as distinct disorders (Cloitre et al., 2018). The questionnaire includes 18 questions 

with Likert scale responses. It assesses both PTSD and CPTSD as distinct diagnoses, and its 

factor structures have been independently validated to support its accuracy in those diagnoses 

(McElroy et al., 2018). The ITQ has also been validated worldwide with diverse populations 

ranging between age groups, geographic locations, and trauma types (Haselgruber et al., 2019; 

Fernández-Fillol et al., 2020). Administration of the questionnaire occurred as part of 

participants’ initial online Qualtrics screening survey. If either member of the couple did not 

meet the clinical cutoff for CPTSD, they were withdrawn from consideration for this study. 

Ultimately, 19 participants met all the criteria for a CPTSD diagnosis.  

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Intervention.  

Therapists involved in this study were either certified in EFT or actively working to gain 

credentials for certification, which meant they were receiving ongoing EFT supervision with an 

EFT trainer. To obtain training in EFT, therapists must either be a master’s level licensed mental 

health professional or under the supervision of a licensed mental health professional in marriage 

and family therapy, social work, or licensed professional counseling. Next, eligible masters level 

trainees participate in the EFT externship, which is a four-day intensive training offered by a 

certified EFT trainer. After that, therapist trainees’ complete EFT core skills training, which 

includes four 12-hour (two day) trainings offered in a similar style to the externship and involves 

implementing EFT skills actively within each training as therapists receive feedback on their 

fidelity to EFT from EFT trainers. To receive full EFT certification, therapists must complete all 

of these stages and then complete additional EFT supervision and submit video footage of their 

ability to use EFT effectively with their own couple clients and gain approval from the EFT 

certification review board.  

Interview procedure. Couples who qualified for the study were then asked to participate 

in a semi-structured interview (Appendix G). The interviews were held online, and they were 

recorded using Zoom meeting software that was HIPPA compliant. Before the interview began, 

the researcher reviewed a number of the study’s elements: the informed consent, an overview of 

the study’s purpose and questions, and the study’s potential risks and benefits. The researcher 

also notified participants that they could choose to not answer any questions or end their 

participation at any point. The interview questions (Appendix G) did not address details 

concerning past trauma that participants may have reported during the screening process. The 

interviewer acknowledge that participants had histories of past accumulated trauma and ongoing 

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CPTSD symptomology as they met the screening cut off. Participating couples asked about their 

experiences with EFT interventions, giving them an opportunity to talk about their own progress 

and discuss the aspects of the model that they found to be helpful and difficult.  

Data collection. The qualitative interviews with each participant couple lasted for an 

average of 120 minutes; they ranged between 78 and 134 minutes. In total, this resulted in 

approximately 20 hours of interview data from participant couples about their experience of EFT 

in the context of CPTSD symptomology and interpersonal trauma-related difficulties in their 

relationship. To ensure the responses were comprehensive, and to ensure that both partners in a 

relationship were given equal amounts of time to respond to the questions, the researcher 

interviewed participating couples together. All of interviews were conducted using Zoom’s video 

conference software. The audio of the interviews was recorded; these recordings were 

electronically encoded and protected with a double password. The interviews were transcribed 

verbatim and transferred to Word documents. These were then stored in files that were 

electronically encoded and double password protected as well. 

Data analysis. In analyzing this qualitative data, I used the framework analysis outlined 

by Ritchie and Spencer (1994) and expanded by Gale et al. (2013). This methodology’s 

procedure includes seven primary stages: (1) transcription and data organization, (2) 

familiarizing, (3) coding, (4) the development of an analytical framework, (5) the application of 

that framework, (6) the incorporation of data into the framework matrix, and (7) data 

interpretation (Gale et al., 2013). 

The first stage of data transcription and management involved standard verbatim 

transcription, de-identification of participant identifiers (i.e., names, exact locations, therapist 

names, etc.), and secure encrypted digital data storage. Due to the large size of the data set, it is 

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considered best practice for framework analysis to a Computer Assisted Qualitative Data 

Analysis Software (CAQDAS), MaxQDA to help manage, store, and code data (Parkinson et al., 

2016; Ward et al., 2013). Within MaxQDA I kept a codebook to organize initial notes, memos, 

and emergent themes after each interview. Through the familiarization stage, which took place 

after the first interview until the completion of the tenth and final interview, I reviewed each 

interview at three to five times prior to coding to develop an in-depth understanding of what each 

participant couple was communicating along with emergent themes across cases (Creswell & 

Poth, 2018; Gale et al., 2013). The codebook was used an audit trail in which I relayed my 

impressions to my advisor who worked with me at that time to develop initial coding categories 

starting after the first three interviews were completed.  

The next stage of framework analysis was coding, which entailed line-by-line coding of 

each transcript in MaxQDA to uncover structures within the data set that then informed the 

initial analytical framework (Gale et al. 2013). Development of the analytic framework was an 

iterative process that developed from building upon emergent themes after the completion of 

each interview and as I received feedback from participants about the proposed framework as a 

form of member-checking, and cross-checking with my advisor (Braun & Clarke, 2006; Pelias, 

2019). Member-checking from involved participants (n=12) highlighted the importance of the 

attachment-reframe, therapist directiveness (present process), and balanced alliance within EFT 

couple therapy.  

In applying the analytical framework, I indexed codes from all transcripts into each 

category of the matrix. This facilitated an organized way in which my advisor and I, as the 

research team, could compare codes across all cases per category. Once this stage was fully 

complete after all interviews were completed and data had reached saturation for the scope of 

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this particular study, the next stage was to chart the data into the framework matrix to summarize 

participant’s subjective experiences across cases under each theme (Gale et al., 2013). The 

research team, my advisor and I, met routinely to cross-check and compare interpretations. This 

process revealed seven categories and 16 themes related to couples’ experiences of EFT in the 

context of CPTSD symptomology (Appendix I).  

Trustworthiness. Creswell and Poth (2018) detail the importance of trustworthiness and 

confirmability in qualitative research, and this was a key consideration in the methodology of the 

current study. As the primary researcher of this study, I worked to ensure there were consistent 

cross-checks and member-checks ensure the confirmability and trustworthiness of the analysis.  

As noted, my research advisor served to cross-check my coding, framework, and interpretations 

of the data. Additionally, within the analytic framework development stage, participants were 

offered the opportunity to provide feedback about the initial framework categories and themes, 

which was conducted under the guidelines of Dansby Olufowote and colleagues (2020).  

Results 

The results of this study indicated the depth to which couples within this sample 

experienced grave difficulties within their intimate relationships, which led to a need for support 

via couple therapy. Couples overall relayed extremely positive experiences of EFT interventions 

and were able to gain tools to support their ability to healthfully develop a sense of connection 

and safety within their intimate relationships.  

Reasons for seeking EFT: A Relational crisis and the need to learn how to be 

together. Participants in this sample experienced pervasive difficulties in their couple 

relationships related to past accumulated interpersonal traumas and CPTSD symptoms. Despite 

these ongoing struggles—that for some, lasted for years or decades—participants described a 

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tipping point within their relationship and/or a triggering event that served as the catalyst for 

their participation in couple therapy. The types of crises disclosed within the sample included 

infidelity (n=6), pervasive sexual problems (n=8), grief and loss (n=4), divorce/separation (n=4), 

illness-inducing stress on the relationship (n=6), and ubiquitous relational strain related to 

ongoing interpersonal trauma symptoms (n=20). Some couples had more than one catalyst for 

therapy participation. These forms of relational crises were described as painful, and participants 

recognized that reaching out for help was critical to their personal well-being and the 

sustainability of their relationship:  

We had a really rough year . . . and the EFT thing has really been like, honestly, probably 

one of the best things for us. . . . I hit a threshold when we were really struggling and 

[from EFT], I got really grounded with myself and I think [my partner] is doing the same 

thing (Brent). 

Though couples elected to begin therapy amidst a distinctive moment or crisis within 

their relationship, couples in this sample also described the state of affairs in their relationship 

prior to seeking EFT as they struggled with CPTSD symptoms. The distress couples experienced 

was also juxtaposed with the stigma surrounding couple therapy and the role stigma played in 

couples delaying couple therapy until the relational difficulties became unmanageable:  

There were like several years where we would have big fights, and then we’d be, like, we 

need to start couples counseling . . . and, like, the stigma around, like, couples counseling 

being for people going through divorce versus, like, couples counseling being something 

. . . really healthy and positive; I had to, like, kind of come around to that. And then we 

were, like, going through, like, a very specific thing that was really hard for us to talk 

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about and manage, and we kind of triggered both of us simultaneously so that like neither 

one of us could support the other (Erin). 

In this way, couples described a cycle of discord within the relationship and the role of 

interpersonal trauma (e.g., avoidance, emotion regulation difficulties, negative self-concept), 

leaving them stuck and confused prior to EFT. As one participant, Janet, noted: 

I think it was, we were stuck. We were stuck. I didn’t understand [why]. And all I would 

know was how to do is try to get my needs met by saying, “What am I doing wrong?” 

And she was so afraid. You [to partner] can correct me if I’m wrong, but she was afraid 

to tell me what was really going on [related to her trauma history]. I didn’t even know 

most of it and I don’t even think she knew. . . . We were, we were so stuck.  

One participant, Matthew, similarly relayed the severity and systemic impact of relational 

distress symptoms within the marriage before he and his wife divorced prior to reestablishing 

their relationship and starting EFT:  

We were both in survival mode. I was trying to just keep the peace. I turned into a rug 

[brushing everything under], and I wanted to shield the kids and stuff too, cause it was a 

pretty toxic, intense environment (Matthew). 

Half of participants did not specifically report having prior experience in couple therapy (n=5); 

however, the other half described participating in couple therapy on other occasions. For some, 

this took place over the course of many years and iterations of couple therapists (n=5) while they 

were still experiencing the frustrating cycle of disconnection and activation within their intimate 

relationship:  

…[we were] well versed in couple’s therapy, you know? I mean, they, it wasn’t just that 

it wasn’t that helpful. It just seemed like we were going the same cycle over and over and 

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over and over and over again, as we have been for years and nothing was really 

improving . . . then it seemed like it was getting worse over the years (Gina).  

Participant expectations of EFT: A changed perspective from solving to bonding. 

Despite the stigma around couple therapy and prior negative experiences of couple therapy, 

participants had a strong desire to work on their relationships. Some participants in the sample 

intentionally sought out EFT specifically (n=6) due to its standing as an evidence-based couple 

intervention, whereas others sought couple therapy in general and ended up pairing with an EFT 

therapist (n=4). Though some participants entered EFT with prior knowledge about the model, 

all participant couples noted a difference between what they expected from treatment and what 

they experienced from EFT. More specifically, couples described entering couple therapy with 

the agenda of “fixing” their relational issues. For example, one participant, Janet, described how 

she and her partner approached therapy initially: “We have this sexual issue. We just need to 

handle this, figure it out and to fix it. We’re super task-oriented people. We’re both educated 

people . . . just give us the fix.” However, participants described how their experience of EFT did 

not magically solve their relational issues but rather helped them restructure how they related to 

their individual relational struggles in a way that lowered their relational distress. This new way 

of relating was facilitated by EFT’s attachment focus, which, as opposed to a behaviorally-based 

intervention, helped identify and then share core emotions between partners. Participant Amy 

detailed:  

I had thought it would be like, you know, like in the triage sense, that [couple therapy] 

was fixing a problem we had, but really, the thing that I hope to get out of it every time 

is, like, to understand [my partner] better and understand how, like, we can be in a 

relationship together and, like, be respectful and happy and healthy together instead of, 

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like, trying to fix all our problems. Like, I’ve kind of accepted that, like, we’re human 

beings, we have issues and problems, but, like, learning about how we both feel about the 

problems and how we can, like, help each other through them is sort of what I want to get 

out of our sessions.  

Participant Experiences of Core EFT interventions. At the time of the interviews, all 

participant couples had been in EFT for at least 8 sessions, but some had been in couple therapy 

for several years. Consequently, participants were able to speak to their experience with most of 

the core EFT intervention components, including cycle tracking, the attachment reframe, present 

process, emotional conjecture, and enactments (the identification and sharing of core [primary] 

emotions between partners). Given the range of participant experiences in EFT (between two 

months and several years), all participant couples were able to speak to their EFT experience, 

and those further along were able to address late-stage EFT treatment, with some couples able to 

speak from a client perspective about the stage 2 components of withdrawer reengagement and 

blamer softening.  

Cycle tracking: A new perspective on couple conflict via the attachment reframe. A 

core component of EFT is the framing of couple conflict through the lens of adult attachment; 

that is, conflict between partners is framed as rooted in the unmet attachment needs of emotional 

safety, security, and accessibility between partners. All participant couples relayed their 

experience of cycle tracking, a core feature of stage one in the EFT model. The paradigm shift of 

identifying what EFT calls the “cycle” or “dance” resonated with couples in terms of how they 

viewed the root causes of their relational conflict. Brittney described this initial process of 

learning about how her external reactions based in the fear of disconnection from her partner 

played a role in the negative cycle of her relationship:  

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I think that’s part of what was brought to our attention in [EFT] therapy was that, like, 

the dance, you know, like, I couldn’t understand [why I was doing] what I was doing to 

get close . . . that dance . . . it was, like, a very, a big awakening . . . when it was brought 

to my attention that, like, why, why was I like obsessively texting him? Or like purposely 

fighting with him, not [consciously]. Cause then he was like, why would you pick a 

fight? I didn’t know what I was doing. I, I just, I didn’t know. I just knew that I didn’t 

feel manageable inside and I wanted his . . . I wanted a connection with him.  

When asked about cycle tracking, Erin provided a salient description of something others 

in the sample described, which was how this intervention (cycle tracking/reframing) shifted the 

relationship between her and her partner in that it helped expose the interpersonal trauma 

symptomology (in this example, negative self-concept and emotion-regulation difficulties) 

driving the negative relational cycle.  

[EFT cycle tracking has] kind of, like, completely changed the way I think about conflict 

that we have. Like, I, I think I never really thought about, like, the reason we’re having 

this elevated conflict is because we’re both having this issue regulating or we’re both 

somehow triggered and the idea of I, as a partner, I can help you regulate and you can 

help me regulate and practicing that in therapy, I think has been huge . . . I think there’s 

so many conflicts we had that I didn’t realize that what was going on was, like, I was 

feeling worthless [related to past trauma]. So, I was, like, flashing [back]. . . . And I think 

even knowing that that’s going on and then being able to name it during a conflict or 

having you [partner] name it during then, it’s, like, oh, it just kind of completely diffuses 

everything. 

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CPTSD couples in this sample resonated with the way EFT prioritizes core emotions 

within cycle tracking, which helped them gain hope for a new way of relating outside of the 

negative, trauma-based reactions. Participants often described the need to get past the distraction 

and relational harm caused by the cycle. Early on in their own experience with EFT, a 

particularly high-scoring CPTSD participant couple who struggled with severe relational distress 

outlined their process:  

Getting to the core feeling. That’s been the best thing actually. It’s like, because we can 

spin for hours, and it’ll turn into bullshit about everything and anything. And then [our 

therapist] will just sort of bring us right back to the pinpoint part and make sure we 

realize what we’re actually talking about. So I guess that’s sort of what I mean by 

reframing, it’s like making sure we’re communicating on the same planet, which is about 

how we feel and how we are blowing up because we care so much about this relationship 

(Brent). 

His partner responded in agreement:  

Yeah, I think to reframe [our conflict], get to the core feelings, and break the cycle. Like, 

that’s what I’m most excited about, is when we can use that to stop it on our own 

(Monica). 

Other participants, like Sarah, who were farther along in EFT, described how they were able to 

make this innate shift by identifying the cycle and seeing past the surface:  

I think it taught us both how to have emotional space for each other, like hands down. 

Like, it’s so easy for me [now] to . . . step aside and say, okay, I understand what I said, 

why it’s upsetting him, like actually getting to the root of it, opposed to just seeing 

[what’s] on the surface (Sarah). 

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Emotional conjecture helped partners name their emotions and express vulnerability. 

Emotional conjecture is an ongoing component that informs cycle tracking and subsequent 

interventions in EFT. One of the goals of this intervention is to uncover partners’ primary or core 

emotions to promote emotional awareness, attunement, and bonding between partners. Often, 

this occurs by summarizing and repeating emotional language back to partners while also 

validating their experience of those emotions:  

I think another thing that [our therapist] does that she’s good at, like, summarizing or, 

like, reflecting our, our emotions and our feelings. So, it’s easier for us to, like, 

understand what I’m feeling and what [my partner] is feeling (Ryan). 

Another reflected:  

I think [our therapist] does a really good job of, like, turning what we’re saying into the 

emotion, does that make sense? Right. Like, so [our therapist will reflect] I’m hearing 

fear or I’m hearing . . . I think it’s helpful, especially for someone like me who doesn’t 

always, isn’t always able to, like, get there myself. Like I need, I need that (Kirsten). 

Due to the heightened and chronic experiences of emotional constriction, hypervigilance, 

reexperiencing, and avoidance within this sample CPTSD population, the utility of emotional 

conjecture was essential. As outlined in chapter 4, participants in this sample often experienced 

their partners through the lens of past interpersonal trauma; however, emotional conjecture 

helped disarm participants’ intrusive and protective CPTSD symptoms to identify and experience 

their own and their partner’s genuine emotions. Participant Kristen noted:  

I think like the translation piece, right? Like, helping us to see, like, what’s actually 

happening . . . the core emotion. Like, I think that piece is, is really important for us as 

two people who . . . really struggle to identify emotions within ourselves and within each 

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other, right. Like, instead of getting triggered by his anger, like, helping me to see like the 

fear that’s there, you know what I mean? Like, yeah. I think that’s been huge . . . in 

validating him, [our therapist is] also, like, naming the emotion and validating the 

emotion. So it helps me see through [my] hurt in order to be empathetic. Right. Like I 

think that piece for me is, like, it, it allows me to, like, step out of my own way. . . . 

Because she reframes it in a way that is, like, oh yeah, he’s just scared (Kirsten). 

This process of emotional conjecture was a positive experience for couples in this sample and 

aided in their ability to access and share vulnerable emotions despite deeply engrained symptoms 

of emotional constriction and avoidance due to past interpersonal trauma:  

[Our therapist has] helped [my partner] open up. Yeah. You know, to where she wouldn’t 

have been able, she probably wouldn’t have gone as much. Right. Or understood that she 

need, that she needed to do that. Yeah. In order for us to grow and get [closer] . . . I know 

[this has helped] because [my partner] told me four words that I hadn’t heard for 22 years 

. . . “I need you too” (Matthew). 

Process over content: redirection to what is important. An essential component of the 

EFT intervention is for therapists to redirect clients to the present process. The here-and-now 

orientation, focusing on process over content, connects couples access their core emotions within 

the session allowing the therapist to help them model the identification and sharing of core 

emotions outside of the session, and to have couples experience a new and emotionally attuned 

way of relating. The present process is, in part, what clients described as different from what 

they expected from couple therapy. This was important because not only do many clients enter 

couple therapy with the agenda of resolving arguments, but this sample of couples in the context 

of CPTSD also managed severe symptoms of reexperiencing and hypervigilance related to their 

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relational issues (n=10), as noted in chapter 4. Participants in the study had a positive experience 

with this EFT component, appreciating that their therapists were able to prevent them from 

getting lost in those symptoms and redirect them back to identifying and sharing their core 

emotions in the present:  

And even, you know, whereas like with the EFT, it’s like [our therapist] doesn’t even 

really wanna hear about the fight. It’s like the feelings that are underneath it. So that’s 

what really resonated (Brittney). 

Her partner added:  

[Our therapist is] really good at redirecting us because we get so easily caught up in “He 

said, she said, and this happened.” The surface level. Yeah. That’s it, and it’s so easy for 

us to bring someone in and wrap them in that tornado. But [our therapist] is really good 

at, like, hitting the pause button and, like, redirecting us. . . . No one’s been able to stop 

the tornado from spinning [before] (Ryan).  

Another participant, Amy, insightfully described how she recognized that the content was a way 

of avoiding addressing more painful emotions with her partner: “it’s almost like you can hide 

behind the talking about the experience.” Participant John further illustrated this experience 

across the sample, which was how he and his partner valued the therapist’s consistent but firm 

shift away from their content and toward their underlying emotional issues:  

The problems that we present [in couple therapy] aren’t really the problems we want 

solved, even though we don’t, you know, don’t realize that. Kudos to those who can 

figure that out. And, but it’s not “about the dishes,” it’s not about the dishes. . . . To help 

people to where they really want to go rather than where they say they want to go. Yeah. 

That sounds a little heartless or dismissive, but I, I actually believe that (John). 

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Successful enactments lead to important relational shifts for trauma survivor couples. 

A key component of the EFT intervention born out of the cycle tracking, emotional conjecture, 

and present process is the experiential exercise of enactments. Participants described their 

experiences of enactments as “uncomfortable, [and] very awkward” (Brittney), even “jarring” at 

times (Monica), yet they were impactful to their initial and sustained progress in couple therapy 

due to the new way they learned to relate to their partners through positive experiences of 

vulnerable emotional expression. Participant Erin illustrated how she and her partner experienced 

this shift:  

It’s like super, super vulnerable . . . at the beginning it was, like, oh, wow, like, we have 

never been this direct with each other about anything ever. It’s just, like, kind of like this, 

like, pure honesty. And I think that that can be really scary, right? Like, if you’re the 

person saying this is how I feel in this moment, that’s a scary thing to say and cause 

you’re also kind of asking not, maybe not directly, but like the implication is, “I need you 

to help me with this.” And then, like, if you’re the person hearing it, it can sometimes be 

really painful because sometimes, like, you’ve caused that really hard feeling or will be 

sad about what’s happening for our partner. . . . And it can get, like, very raw as you peel 

back the layers together.  

For some, especially those in the sample still in early stages of EFT, enactments remained 

difficult and surprising. One participant, Mitchell, noted, “I’m supposed to be the emotionally 

disconnected one and I welcome it. She hates [enactments]” (Mitchell). His partner followed up 

to share another common thread across participants, which was the aftereffects of enactments 

and their application outside of therapy:  

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It is very challenging; [however], I feel like we’re making progress with it. I feel like it’s 

helpful in that if you were looking at our session and watching it, you probably would 

think it’s not helpful, but I think it is helpful because even if I cannot do it in the moment 

. . . I am able to do it later or I’m able to, like, address whatever that was later. . . . I’ll just 

sit there and stare at him and, like, nothing will come out. . . . But I don’t let it go. Like, 

so it is helpful because I am still processing that and still like coming back to it (Kirsten). 

Enactments that went well translated into real-life conversations outside of session, 

something these trauma surviving participants struggled with. One participant, Ryan, shared that 

after enactments in session, “it makes it easier then, in real life to turn to her and say what I feel, 

that’s how I learned to kind of turn to her and say what I need, no matter how uncomfortable it 

was.” Indeed, participants described that the more they experienced enactments, the more this 

modeled a new way of relating to their partners that felt safer, more authentic, and more secure, 

which stood in stark contrast to their chronic experience of feeling unsafe and/or insecure in their 

close relationship due to CPTSD. One participant, Ryan, who, like the rest of the sample, had 

significant struggles of relational distress in his relationship due to CPTSD, expressed how 

enactments helped him and his relationship:  

That process where they’re going to my core emotions, looking at it, evaluating it, talking 

about it and, like, putting a sense of, like, a safety net around it in a way; then having [my 

partner] address whatever thing [was] is powerful. And it’s not just to me, but also, like, I 

have the opportunity to see exactly what emotions she’s feeling too and the mechanics 

kind of surrounding that it has nothing to do with the fight . . . but it’s all about those raw 

emotions and feelings underneath for us both, and by just looking at it and examining it 

has helped me with those [trauma] triggers (Ryan). 

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Though some participants were still in early stages of change related to enactments, it 

was clear that overall, enactments had a powerful impact on couples in the context of CPTSD. 

Their experience of relational distress, negative self-concept, and insecure attachment were being 

altered due to couples’ new way of relating, which Participant Erin described as:  

It’s kind of like night and day [from before therapy], honestly. She has us talk to each 

other. I feel like I imagine therapy just being, like, talking to the therapist, but she 

actually has us, like, practice talking about our deep emotions to each other and telling 

each other what’s going on, which is just really helpful in our actual relationship day to 

day. And I think, like, that’s why we’re much better now about, like, the way we handle 

conflict and I think that that’s really helpful. And I think, like, now we’re kind of, like, 

inching towards at least what I hope, is, like, as we continue to support each other, like, 

some of those feelings that I have of insecurity, like, hopefully lessen, like I will feel 

more secure. It’s, like, in progress (Amy). 

Another participant described how experiencing her partner’s vulnerable emotions unlocked 

something for her that helped her experience her partner outside of her trauma:  

There was a moment where he looked right up close in my face and said how much he 

loved me and how much my leaving hurt him. I saw it, I saw it in his eyes. . . . I don’t 

know how to even put words to it, but after that, like, everything changed . . . now, I still 

struggle to feel like it’s okay, it’s okay to need someone, to need him, nothing is linear, 

right, but I feel like I can take that risk now, where before I just couldn’t. Not after 

everything I’d gone through (Annette). 

As a result of enactments and related EFT interventions, couples in the context of CPTSD in this 

sample were able to more effortlessly take what they had learned in session to their relationships 

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outside of sessions, where they could “feel each other’s pain” (Sarah), which subsequently 

enabled them to offer the support described above:  

We are able to turn to each other and speak directly to each other and many times I can 

see how [my partner] feels based on what I’m saying or how she might be reacting 

differently based on what I’m saying (Harry). 

Participant Experiences of the EFT Pursuer and Withdrawer Framework  

Due to the extensiveness of the interviews, and the varied length of treatment and 

therapeutic needs across the sample, not all participants went into detail regarding interventions 

from the later stages of EFT but rather focused on the key components of the EFT therapy in 

general and in stage 1. However, participants were able to speak to the core EFT themes of 

withdrawer reengagement and pursuer (or, blamer) softening. Withdrawer reengagement occurs 

in stage 2 when the withdrawing partner is able to express their fears around the relationship to 

the therapist and their partner. Blamer softening is a key intervention that follows withdrawer 

reengagement. This intervention involves facilitating a process for partners to explore and 

express their fear-related views of their partner and to reach out to their partner to experience 

support, validation, and connection amidst those fears in exchange for self-protection and 

defensiveness against their partner.  

Withdrawer reengagement: shifting out of protection mode. One participant, Cathy, 

relayed how difficult it was for her to shift into engaging with and exploring her emotions due to 

past trauma and her symptoms of emotional cutoff, a common traumatic stress experience across 

the sample: 

So I think emotions in general are really, really hard. Okay. I have to tell you; I think I 

explained it. I am 54 years old, and I’ve lived pretty much 53 years without feeling a lot 

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of emotions. Or at least not things that weren’t, you know, super basic like happy, sad, 

mad [laugh], right? Pretty basic stuff. So, it’s been, it is super hard work. I mean, it’s, you 

know, sometimes it’s really hard to even go there, but I know it helps me and helps us 

(Cathy). 

It cannot be overstated how painful and sensitive exploring emotions was for the more 

relationally withdrawn portion of the sample (n=11), over half the participants, which was also 

reflected in chapter 4 under emotion-regulation difficulties (constricted emotions). Due to the 

increased difficulty of emotional engagement for survivors, many in the sample spent some time 

within treatment or were still in the stage of “just ignor[ing] it, and . . . not lik[ing] it” (Mitchell). 

However, even early on there was a sense of becoming “more receptive to it” (Mitchell) as 

emotional safety was established.  

The process of withdrawer reengagement was best defined and expressed by Participant 

Annette and her partner, Matthew. Annette detailed the transformative process of experiencing 

emotional safety with her EFT therapist and her partner, which enabled her to make the decision 

to open up and express her need for her partner after many years. This is notable, as participant 

couple seven, Annette and Matthew, divorced after 22 years of marriage due to the increasing 

impact of untreated CPTSD symptoms. These symptoms manifested most prominently as 

emotional disconnection, relational hypervigilance, avoidance, and fear/distrust of close 

relationships for both partners but particularly for Annette, who expressed a prior negative self-

concept related belief of “I don’t need [my partner], I don’t need anyone.” She further noted that 

EFT, combined with individual trauma treatment, has been helpful for her recovery in this area, 

and she defined the specific benefit of EFT:  

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It’s been a cumulative effort, but I think that where [EFT] brings value to the table is to 

clarify for me, like, you know, [the withdrawing] is not that I’m a cold-hearted bitch, you 

know what I mean? Like, I am in protection mode. Yeah. Like, and so I think just having 

that clarification of, you know, this is the behavior, but [the trauma] is why, like, this is 

the emotion attached to it. Like, I haven’t really ever had that. . . . I’ve never experienced 

that before. I’ve never understood the connection (Annette). 

Her partner recognized, after also stating his recognition of how difficult this process was for her 

due to her complex trauma history, “[EFT] helped her to open up and actually allow herself to 

feel, and then show me those feelings, which has been incredible” (Matthew). Participant 

Annette followed up to share the importance of not only awareness of her feelings but the 

decision to choose how she shares her vulnerable emotions:  

Well, [EFT] helps me understand why I’m not, why I won’t [allow myself to feel] . . . but 

now that I understand why I do that, like, and because I understand it, now I get to make 

that decision. And, and at the same time, [our therapist is] working to develop a safe 

space for me. To help me make that decision to open up by creating a stronger level of 

connection between us. It has, it has given me the strength and confidence—and 

especially with what I’ve seen in our progress—to go forward and feel again. I was gonna 

go back in a box again, but I was able to find the trust, I guess, to open back up. And take 

the risk for, for what I know is ahead. 

Participant Matthew again responded to how Annette’s emotional reengagement helped him feel 

more secure in the relationship as well: “[because] I’ve seen, I’ve seen the growth in [my 

partner] and I’m like, you know what, I’m going for it. I’m going to take that risk too.”  

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Getting past blame: ‘all I saw was my pain’. Though the interview did not specifically 

address the blamer softening event in EFT, there was a great deal of discussion around how EFT 

helped them restructure their former patterns of blame resulting from feeling “attacked” 

(Mitchell) or “on the defensive” (Evan) due to past experiences of relational instability. 

Participant John described how acceptance of core emotions, along with the attachment frame in 

EFT, instilled a paradigm shift over time in his approach to the relationship, helping him shift out 

of placing blame on his partner:  

I think it relates back to what [my partner] was saying too about, about what blame is I 

think, you know, in the, in the past I would be upset and I, and I would, you know, 

struggle hard to, to vilify [my partner] because, you know, I thought, if something is 

wrong or if she is upset, somebody’s to blame here. So it’s either her or me, and I’d 

rather not be that person. Right. Um, so part of it is the, you know, that realization from 

EFT that, um, I don’t, I don’t have to place the blame somewhere. . . . I think another part 

is better acceptance of myself since I have felt validated in [EFT] therapy that I have, you 

know, less—it is probably tied into this blame thing—but less need to, to, to feel perfect 

or, you know, yeah. Less need to feel that I haven’t screwed up (John). 

Again, though partners did not relay details regarding specific blamer softening events, 

they were able to share the importance of how EFT manages blame within couple conflict and 

how initial cycle tracking can inform how couples view blame within the context of their 

relationship. As one participant, Monica, described:  

One big thing that’s honestly been a lot to take in, starting from the cycle to now, like, is 

how when I was so upset and afraid, and blaming him, I was actually really hurting and 

attacking him. I was so stuck in my hurt, my trauma, my whatever, I didn’t even know I 

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could hurt him because all I saw was my pain. So getting past the blame thing was really 

big for me and for us (Monica). 

EFT’s handling of blame for CPTSD was powerful and important due to couple 

participants’ often heightened defense reactions based in their symptomology:  

I think that’s the other thing EFT does, is it doesn’t shut one person off. It explains the 

other person’s point of view, but it somehow does that by validating the other person’s 

feelings at the same time. And I think regular couples counseling is, like, it’s either one 

or the other is to blame. And neither of us wanted to find out we were to blame, so we 

would blame each other. It was always one person is fucked up here or one person’s dead 

right and that’s it. But in EFT, blame isn’t there (Evan). 

General Couple Therapist factors. 

 To differentiate between participants’ experience of the EFT model and therapist factors, 

participants were also asked about their experience of their therapist in terms of alliance, 

emotional safety, and attunement. Though these factors are not necessarily unique to EFT, they 

are a large part of the training and deeply intertwined with the model. It was also clear that these 

therapist factors were important to this sample, as survivors of interpersonal trauma are more 

sensitive to interpersonal factors overall.  

Balanced Alliance: Helping ‘us’. Participants shared across the sample that they not 

only experienced a strong alliance with their therapists, but they also expressed the importance of 

how their therapist’s positive regard and attunement was felt mutually between partners. In 

essence, they each expressed feeling personally aligned with their therapist, but overall, they also 

felt it was important that their therapist was “for” them as a couple, which helped couples feel 

secure in the difficult process of couple therapy. Participants noted, “I felt like with [our 

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therapist], I felt like she was helping us. That’s why I stayed. Like I got that feeling from her, 

like she has our back” (Mitchell), and, “[our therapist has] been amazing at accepting both of us . 

. . rapport is . . . important” (Harry), and, “I feel like [our therapist] is out for the benefit of us” 

(Matthew). One participant, Ryan, went on to describe how this was not something they 

experienced in prior couple therapy, which eventually led to dropping out of treatment: 

[Our EFT therapist is] unbiased. And I think that’s different for us. I think there were 

times where it was clear that the counselor [before] was like siding with one. . . . So I’m 

glad that [our therapist] does not do that because that is the thing that kind of keeps us on 

track. Cause I know if [my partner’s] feelings don’t get validated or my feelings don’t get 

validated, it’s gonna derail. Right. That was the cause of derailments in the past. 

Genuine emotional safety from therapists facilitated the therapeutic environment. The 

creation of emotional safety was another therapist factor that allowed clients to not only stay 

committed to therapy but also helped them make therapeutic gains within their relationship. 

Participant Sarah remarked that with their current therapist, “you feel comfortable, you’re not 

guarded, [you are] safe. Just the things that you want in your relationship, we feel that with her. 

So it allows us to do the work.” Participants noted the additional relational benefit of their 

therapist modeling emotional safety. One participant, Mitchell, noted, “[my partner is] getting 

what she needs and I’m learning how to do it [for her].” Another participant, Amy, described 

how therapist rapport, safety, and attunement was established though the therapists’ focus on 

taking the time to really hear and understand each partner:  

I think I want therapists to know that it does make a difference to take the extra time to 

build that trust and to have the difficult conversations. The focus should not be that 

content-oriented stuff. It’s more about how each person is feeling and, you know, really 

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giving the time and respect to each person’s feelings individually, even if it takes like an 

entire session, [the therapist] shouldn’t be afraid to do that and to really understand the 

emotional experience of each person (Amy). 

Participants perception of the fit and acceptability of EFT in the context of CPTSD  

EFT was a good fit and a positive experience for CPTSD couples. All participant 

couples offered salient descriptions of how EFT helped them either initially or significantly over 

time in how they experienced their partners differently based on their new understanding of their 

partner’s inner experience related to past trauma. All participants described a positive experience 

of EFT with their current therapists and relayed how EFT fit well with their relational needs as a 

couple in the context of CPTSD. One such example is indicated by two participants, Harry and 

Rachel:  

EFT has helped me to [understand what’s important] not necessarily solving any problem 

but understanding how [my partner is] feeling . . . and validat[ing] that I understand how 

she is feeling. Things that trigger her are not just caused by what I do or don’t do but are 

also caused by the childhood trauma and then combined with trauma that, that I caused in 

our marriage. . . . Me understanding that and accepting that also helps me because it’s, 

like, yes, I may have done something, but it’s not always just about me hurting [my 

partner’s] feelings. It’s also about how what I did reminded her of the other trauma, and 

that causes it to go from a big deal to a massive deal, you know, so EFT has helped me 

to, to see, to see all that (Harry). 

His partner responded:  

Yeah, because of EFT, I think you experienced me in a way that most people don’t. 

Because of EFT we’ve gone through things, and you’ve heard things and understand 

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things about me that nobody in the world understands. I think that helps a lot with our 

connection. It’s why we are still married and why I can start to even turn to him when 

I’m struggling (Rachel). 

Participant couples described the depth of impact they experienced from EFT amidst 

interpersonal trauma from their childhoods, prior partners, and each other and how this supported 

their families as a whole:  

I mean, we started EFT to save the marriage, so I wouldn’t lose my wife. It was so we 

could increase our communication or not even increase, like, actually learn how to 

properly communicate for the first time ever, even after other couples’ therapy. I would 

say not even make it better, but, like, we had zero clue on how to communicate and it 

turns out that we actually can do it. And what I hope to get at in the future is, like, a nice 

calm marriage. That’s what I hope to get out of this is to get a more calm, peaceful 

marriage, because if we’re not okay, then the kids aren’t. So it has to kind of, like, start 

with us. And that’s what I want more of. I want more of, like, this, what we have now 

(Ryan).  

EFT facilitated a new way of relating: Co-creating safety in the context of trauma 

symptomology. Partners, especially those further along in the EFT (indicated by length of time in 

treatment and treatment stage indicators, i.e., those in or past stage 2), detailed a shift in their 

bond and emotional connection. While barriers to emotional connection related to past trauma 

were common for couples in the sample prior to EFT, the intervention established a new way of 

relating where partners experienced sustainable emotional connection, safety, and accessibility 

within their relationship.  

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Participant partners remarked how EFT helped them relate differently, even early on in 

treatment: “I’ve been really impressed with just how much has been addressed in such a short 

period of time already. So, I have high hopes for EFT” (Monica), or, “Yeah, it’s kind of 

interesting. It hasn’t specifically addressed our trauma, but it’s definitely addressed how we deal 

with each other because of it” (Brent). Even when the trauma was still unresolved, EFT couple’s 

treatment helped participants to live with the trauma. One participant couple, Mitchell and 

Kristen, relayed a similar experience regarding how EFT helped them become aware of how 

trauma shows up in their relationship and how it impacts the relationship.  

I think that we’ve learned more about, I don’t wanna call them triggers. But we’ve 

learned more about our own pasts and we’ve learned more about that, how that impacts 

[us] (Mitchell). 

Partners were able to identify sustainable change by way of a deepened emotional connection 

and co-regulation, which they attributed to gains made in EFT therapy:  

if we, if we didn’t go to therapy, when all this [relational crisis] happened, we wouldn’t 

know how to deal with all the triggers and the reactions and yeah. So yeah, it had a direct 

effect on the relationship, but because we went to EFT and we learned how to manage 

that and become aware of it, I feel like it doesn’t have as much an effect at all (Ryan). 

His partner responded:  

…yeah, like, I don’t even know the last time we had a fight since starting EFT six months 

ago, like, that’s just not what happens anymore for us like it used to. I would panic and he 

would panic and it would just blow up, but now we can help each other when we are 

scared and give each other what we need (Brittney). 

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As illustrated by all couples to varying degrees depending on their progression in EFT, 

one participant, Sarah, described how emotional connection between herself and her partner was 

a “new normal.” Her partner described, “I was emotionally unavailable for years. And now I 

think that I am, at times, still [unavailable], but it’s a whole lot more obvious when I do shut 

down” (Evan). This participant couple further illustrated a theme from the study, which was how 

ongoing treatment led to a new relational state where emotional disconnect was experienced as a 

surprising exception rather than the norm due to the sustained shift toward emotional connection 

in EFT. As Sarah described:  

…definitely a lot of improvement and more so in the last year (while in EFT). . . . So I 

think he’s right, so [when] he now becomes emotionally detached, it’s almost, like, you 

know, you just pumped on the breaks real hard, and you got whiplash because you’re 

almost not expecting it. . . . And we’ve never left a session angry or upset with each other 

. . . we’ve actually gone into a session a few times angry or upset with each other, [but 

EFT] helps tremendously. Like you feel it’s different—I don’t know how to articulate it 

well—but you leave it feeling a different kind of a way with each other. It’s pretty 

incredible . . . it’s [also] more rewarding than, I guess, just regular therapy, and I don’t 

want to take away from it, but it’s really different. It’s a different experience and the big 

takeaway for us is that . . . we leave not ever upset with each other and if anything, 

understanding of the other partner better (Sarah). 

Her partner relayed the depths of their struggles due to CPTSD and how their EFT therapist 

helped them reach a milestone of 20 years of marriage while they have also healed many 

interpersonal wounds both within and outside of their relationship:  

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the last two years have been our hardest two years, even though we’ve made it through, 

you know, 20 years of military service, four years of me being gone away from the 

family, you know, in another country, death, issues with raising our son. We’ve gone 

through all that, but this is the hardest part that we’ve gone through. And I think the fact 

that we had our EFT counselor . . . I think is one of the biggest reasons that we’re able to 

still be here and we make jokes about it. We’re like, thanks for keeping us together so we 

could celebrate 20 years (Evan). 

Trauma therapy competency is key. An important experience for this sample was 

therapist competency in trauma-informed care. This was due to the extent of trauma within each 

couple’s history and how each partner brought their own experience of being additionally 

impacted by their partner’s trauma. As Brittney noted, “I think there was a lot for us to work 

through . . . there was like a lot of trauma upon trauma. A lot of trauma” (Brittney). One 

participant, Janet, recognized that in terms of therapist competency, it may be hard for a new 

therapist to “cut their teeth” with a couples case when a high CPTSD symptomology is present.  

Participants further described how important it was that their therapist had been trained 

and was personally allied with their population and specific needs. One participant, Gina, 

discussed the importance of therapist competency related to trauma for couples:  

I don’t, I don’t see how any couple therapy could be effective without taking, taking into 

account the trauma that comes into it ’cause you bring so much into the relationship. You 

can’t just give people a set of tools and say, here do this, you know, that’s, there’s no way 

it will never, ever, ever work (Gina). 

This sentiment was also important for participants who were not only part of the CPTSD 

population but the military population as well:  

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[Our therapist] also understands the community. And I think that’s probably why we have 

one of the bigger connections with her . . . the fact that she understands a lot of that stuff 

too, some things don’t need to be said, like she understands the stress [my partner] has to 

absorb when I was doing my job overseas, she already gets that. So that makes it, like, 

she’s not saying things that are off putting or saying things that are like, oh, I think I 

understand what you mean when you say this—she, she already gets it (Evan). 

Finally, participants in this population described appreciating therapists who took a “non-

pathologizing” (Cathy) approach to their trauma and trauma symptoms:  

The key has been having a therapist who does not does not label me . . . but really helps 

to put my experience in context. Yeah. I think it’s huge for me and it’s helped me a lot in 

accepting my own experience (Rachel). 

Participants preferred EFT in comparison to prior relational therapies. Participants 

described a stark difference between EFT with their current therapists and prior experiences of 

others forms of couple treatment with non-EFT therapists. Unfortunately, participants expressed 

negative experiences with prior couple therapists and described that overall, their “strategies 

were not good” (Kirsten). What couples described most about prior experiences in non-EFT 

couple therapy was that it did not help, and in that sense, their ongoing relational distress, despite 

seeking help, was harmful. In this sense, participants relayed how EFT’s attachment framework 

was particularly well suited to their needs compared to other approaches in couple therapy: 

My [individual] therapist does do EFT. And then also does like attachment theory and 

I’ve, I’ve noticed that I’ve responded really well to that . . . in the past we’ve gone to, I 

think, maybe like two or three marriage counselors, like, in our, in the past 12 years. And 

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really what we find is that we spend the session just replaying the fights, and then that 

creates, like, more of a fight (Brittney). 

One participant, Gina, described another experience of ineffective couple therapy:  

We did do couples therapy, um, through two sets of people, um, prior to EFT . . . we were 

with one therapist and we were with her for quite a while. A lot of years before we finally 

saw the light and said, this just, this just is not effective. She was like a band-aid, you 

know, it’s like, okay, you can go there and you can fight in front of her for an hour, but 

then, uh, you know, and then, and to get some of those feelings out, but then, you know, 

never really resolve anything (Gina). 

One participant couple noted that they found EFT through a referral to the EFT workshop series 

“Hold Me Tight,” which became the catalyst for them switching from general couple therapy to 

EFT: 

We were actually in couples therapy, for a while, and it just wasn’t working. We would 

come in mad, we’d leave mad, stay mad. So our therapist sent us to an EFT workshop 

thing, kind of, probably out of desperation, like, “here, you take them,” and it made so 

much sense to us, so we switched to EFT and never looked back (Evan). 

EFT with CPTSD couples: Barriers, critiques, and suggestions 

 When asked if participants experienced any barriers in EFT to achieving their relational 

goals, participants shared key critiques or recommendations from their perspective for how EFT 

therapists can best treat couples with CPTSD.  

The importance of a collaborative process. A theme that arose was the importance of 

clients’ ability to feel connected and oriented to EFT in two ways; understanding the process, 

and timeline. Participant Kirsten noted that a “loosely defined process, probably would’ve been 

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helpful sooner” (Kirsten). Other participants noted that their therapists did offer a clear map of 

the EFT process early on and noted that this was helpful for them to understand the goals of EFT 

and how to “trust the process” (Erin). Therefore, it stands that clarifying the processes and goals 

of EFT may be an especially important ingredient for establishing a sense of direction and 

security when doing EFT with a trauma-exposed population.  

Similarly, the time frame of doing EFT with trauma-exposed individuals is a debated 

topic among therapists, and this particular sample offered more insight into this discussion; 

namely, they felt that time constraints were misleading for their needs. Participant Rachel 

remarked:  

So there was this idea with EFT that it may only require 6 or 12 sessions. I think putting 

any number down is wrong. Okay. I would not put, I would not put any number on how 

many sessions it might take with this couple or that couple (Harry). 

Another participant, Gina, went into more detail regarding why the time constraints may not 

work for a relationally traumatized population due the layers of complex emotions and safety 

required:  

I mean, maybe I’m speaking through a trauma lens having, you know, having grown up 

with a lot of trauma, but it seems to me that it would be very, very difficult to just have a 

short course of, you know, a six-month course of EFT and be all better, you know? I 

mean, but maybe if you, if you didn’t have a hugely traumatic background; neither 

partner did have a, a lot of trauma. Maybe it can go a lot faster, you know, but I don’t. 

Yeah. I don’t know. I dunno if that’s the goal. I mean, obviously it’d be great if 

everybody could get help fast. . . . I don’t know if it, I don’t know if it’s realistic. 

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Participant, Cathy, described being grateful for the long-term therapy experience with her EFT 

therapist and the recent breakthroughs she experienced due to a longer form (three years) of 

EFT-specific treatment.  

[Our therapist] was there and she is stuck with us. . . . My trauma started when I was 

three years old, probably younger. . . . I’m 54 years old and I’m, I’m not lying when I say 

just in the last six months to a year, I can start to say that I have hope that it’s gonna get 

better, and that’s not against [my partner or therapist]. That’s how long it took. Yeah. 

And all my life I’ve been dedicated to working on this in one way or another and I’m 

finally getting some relief. (Cathy) 

Visibility and accessibility of EFT for CPTSD populations. Participants described a 

few indirect barriers to EFT, more specifically related to a lack of awareness about the model 

and access to therapy and EFT therapists, which supports the expansion of services and the 

dissemination of EFT for trauma-exposed populations. A theme across couples was their lament 

that they did not “learn about [EFT] sooner” (Gina). As one participant, Monica, noted: 

I guess I didn’t really know that EFT existed, first of all. And secondly, I didn’t know 

that it would’ve been beneficial, specifically, for people with trauma. So I don’t know, 

like, it would’ve been nice to have this knowledge previously. So, I guess the only thing I 

could say, really, is, like, somehow making it more visible.  

Another participant couple summarized the importance of accessibility both in terms of financing 

therapy and physical access, which in this case, was aided by the expansion of telehealth:  

We are privileged to have the time and resources to pay for and have time for this 

treatment . . . to be honest with you, when COVID hit and we could go to video 

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[sessions], that was the best thing. . . . I never found the therapy itself difficult, but the 

logistics were hard. (Janet). 

Cohesive care and the meaningful integration with individual therapy. All 

participants described meeting with individual therapists throughout their lives, some during 

their EFT treatment, and they had primarily neutral or positive experiences. In this group, 

participants relayed they did not feel they needed or significantly benefited from individual 

therapy over time after experiencing EFT, noting, “I don’t know, but I think it’s, like, way more 

useful than just therapy by yourself, because everything I’m dealing with applies to us, and same 

for [my partner]” (Erin). Another participant said, “it just makes sense to kick everything back 

into the relationship because we are both dealing with all of this anyway, so we need to work on 

managing it and healing together” (Janet). 

Conversely, in terms of the interaction of EFT with individual care, some participants felt 

that having additional individual care was both useful and that it offered a different but 

supportive service to their work in EFT in the context of their traumatic stress symptoms. As 

participant, Harry, relayed the usefulness of his partner’s EMDR and how it helped both him and 

their relationship: “I do feel like it really helps when she kind of debriefs with me about her 

EMDR, it really helps me learn a lot about what’s happening for her.” In this way, couples 

relayed the importance of awareness of and cohesion with what was happening in individual care 

and their couple work in EFT in terms of therapeutic goals and being able to support and better 

understand their partner’s experience.  

Discussion 

Cumulative empirical literature from the traumatology field has called for an expansion 

of traumatic stress interventions to identify effective treatments for CPTSD (Bryant, 2022; 

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Chouliara et al., 2020; Cloitre et al., 2011; 2020a; 2020b; Coleman et al., 2021; De Jongh et al., 

2016; Forbes et al., 2020; Forde & Duvvury, 2021; Gerge, 2020; Karatzias et al., 2019b; 

Lonergan, 2014; Matheson & Weightman, 2020; Monson et al., 2022). The literature further has 

recognized the essential nature of integrating relational features in treatment, which includes the 

participation of a patient’s social system, especially family members (Banford Witting & Busby, 

2019; Stadtmann et al., 2017; Van der Linde & Edwards, 2013; Volgin & Bates, 2016). 

Similarly, the systemic family therapy field had identified couple interventions (Baucom 

et al., 2014; Doss et al., 2022; McWey, 2022), and EFT specifically (Blow et al., 2015; Dalton et 

al., 2013; Greenman & Johnson, 2012; Karris & Caldwell, 2015; MacIntosh & Johnson, 2008; 

Roundy, 2017), as effective treatments for trauma-related interpersonal distress. The current 

study was the first of its kind to examine couples’ experiences of EFT within the context of 

CPTSD symptomology to better identify the fit and acceptability of this intervention for CPTSD-

specific populations.  

Findings from this analysis revealed categories of participants’ experience in EFT, which 

first illustrated how CPTSD symptoms within the relationship became impairing and 

unmanageable for couples (Webb et al., 2022), which in turn led to or exacerbated relational 

crises and eventually led to their participation in EFT. Couples in the study experienced EFT as 

providing relief to their underlying trauma symptoms of relational disturbance within their 

couple relationship.  

The findings from the current study add support to prior clinical PTSD research with 

couples while also expanding to include a CPTSD-population perspective on EFT treatment 

(Blow et al., 2015; Oseland et al., 2016). Specifically, findings from this analysis were in line 

with the clinical application of the CATS model, which highlights the importance of safety and 

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stability (for the individual and couple), conjoint trauma processing, and emotional connection 

between partners as core clinical components for couples in the context of trauma (Oseland et al, 

2016). Additionally, this analysis also supported the use of EFT for couples in the context of 

PTSD (Blow et al. 2015; ; Dalton et al. 2013; Greenman & Johnson, 2012; Karris & Caldwell, 

2015; MacIntosh & Johnson, 2008; Roundy, 2017). The current study adds specificity to these 

findings, and it expands to include the context of CPTSD as a distinct traumatic stress disorder, 

bolstering the case for using EFT for couples in the context of CPTSD.  

Reasons for seeking EFT: A relational crisis. In line with the current literature, couples 

in the context of CPTSD experienced pervasive and extensive difficulties in their relationships 

(Banford Witting & Busby, 2019; Cloitre et al., 2020b; Herman, 1997; Hyland et al., 2017a), 

which eventually led to an unmanageable crisis in what participants described as the most 

important aspect of their lives, their close relationships. These ongoing struggles, in conjunction 

with developing relational crises, led couples to EFT, which they sought out both intentionally 

and unintentionally. As noted, almost all couples had extensive prior experiences in couple 

therapy and eventually dropped out before switching to EFT. Participants described a common 

theme in their experience of EFT, which was the shift from what they expected to get out of EFT 

versus what the intervention actually entailed (Wiebe et al., 2017). A common thread for couples 

related to the shift from their expectations of couple therapy as a fix for their relational problems 

to their lived experience of EFT as an emotionally focused, experiential, and attachment-based 

therapy, which altered the core dynamics of their couple relationship (Greenman & Johnson, 

2012 ; Wiebe et al., 2016; 2017).  

EFT with CPTSD couples: Experiences of EFT interventions. Couples in this sample 

took part in EFT of either consistent (weekly) or, eventually for some, intermittent (as needed) 

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treatment, ranging from, at the time of the interview, eight weeks (n=2) to almost ten years 

(n=2). However, most of the sample reported between six months and three years of active 

treatment (n=16). Within this sample, all couples reported meaningful therapeutic gains from 

their experience of EFT. This included couples earlier on in treatment as well as those who were 

further along in stages two or three of EFT. These findings support and expand upon prior 

studies and reviews that indicate the probable fit of EFT for CPTSD populations (Blow et al., 

2015; Dalton et al., 2013; Johnson 2002; Macintosh & Johnson, 2008; Roundy, 2017).  

In terms of couples’ experiences of specific EFT interventions, findings revealed this 

sample benefited from and distinctly recognized the value of EFT core components. Stage one, 

or the de-escalation stage of EFT, employs several key interventions that aim to restructure, 

reframe, and deescalate couple conflict by helping partners identify and access core emotions 

and placing the “blame” for couple conflict on the cycle and unmet attachment needs of 

connection between the couple (Johnson, 2004; 2019). The attachment reframe, identification of 

core emotions, and the language of the relational cycle itself resonated deeply with participants. 

Chapter 4, along with prior studies, have illustrated increased difficulties with escalation between 

partners within the context of interpersonal trauma and related symptoms, along with increased 

insecure attachment styles related to CPTSD sequala (Blow et al., 2015; Dalton et al., 2013; 

Johnson 2002; MacIntosh & Johnson, 2008; Roundy, 2017).  

Couples in this study identified strongly with the attachment framework of EFT. The shift 

from experiencing one’s partner through the lens of prior trauma and toward experiencing 

partners through the lens of attachment, heightening core emotions, and validating their 

experiences was powerful for couples as a result of EFT. This framework helped alleviate 

couples’ experiences of their partner as the “problem” or “unsafe” person. The sample reported 

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that the attachment frame was a key component that helped them to manage experiences of fear-

based arousal surrounding their partner or the relationship as a trauma stimulus. Lowered arousal 

surrounding the relationship was facilitated by therapist attunement and emotional conjecture, 

which led to a subsequent awareness and sharing of core emotions in the present moment 

between partners (enactments). Enactments, though difficult initially, were impactful and built 

empathy and mediated against internal signals of defensiveness and trauma-related avoidance 

between partners (McRae et al., 2014; Wiebe et al., 2017). In other words, by recognizing their 

partner’s vulnerable emotions, and supported by emotional conjecture and enactments, CPTSD 

couples could start to experience each other beyond the trauma lens of avoidance, fearfulness, 

and defense. Over time, participants reported that the positive experience of enactments in 

therapy translated directly to their way of relating in their day-to-day relationship outside of 

therapy. 

Findings further revealed the sample’s positive experience of the “here-and-now” 

orientation of EFT (Johnson, 2019; McRae et al., 2014; Wiebe et al., 2017). EFT therapists’ 

focus and constant redirection toward couples’ emotional process, rather than addressing the 

content of their conflict, was notably beneficial for this sample and resonated deeply with 

participants. Though this aspect of the EFT intervention is highly directive, participants distinctly 

recognized this and indicated that it directly restructured the way they understood each other and 

managed conflict. In this way, participants relayed a paradigm shift in their relationship, moving 

from deeply rooted, fear-based responses—riddled with hypervigilance, reexperiencing, 

avoidance, negative self-concept, and emotion regulation difficulties—to more calm, curious, 

and empathic methods of co-regulating amidst difficulty (McLaughlin et al. 2015).  

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Findings revealed that the development of attunement via emotional accessibility and 

responsiveness between partners was a powerful clinical result of EFT for trauma-exposed 

couples, which is in line with Greenman and Johnson (2012). Shifting cycles of emotional 

distance and anxious pursuit between partners addressed core CPTSD-related symptomology of 

emotion regulation difficulties, emotional avoidance (in the form of withdrawal), and 

hypervigilance in the form of blame and reactivity (chapter 4).  It also prevented the spiraling 

down of couples when one member was triggered (McLaughlin et al., 2015). Participants relayed 

the relief they experienced being able to co-regulate with their partners amidst distress, despite 

the prior barriers related to fear-based CPTSD symptoms (Randal et al., 2021; Roundy 2017; 

Wiebe et al., 2017).  

Therapist factors. Importantly, therapist factors, including a balanced alliance with both 

partners, emotional safety and attunement, and trauma-informed care, were viewed as highly 

important for participants to experience a positive therapeutic environment (Blow et al., 2007; 

Chouliara et al., 2012; Davis et al., 2012). Participant couples in this sample experienced their 

therapists as unbiased, emotionally safe, attuned to their needs, and trauma informed. For this 

particular sample, participants reported trauma-informed components from their treatment, 

including therapists validating their experiences, therapists’ nonjudgmental stance, and, 

importantly, therapists “sticking with them” and allowing clients to process and proceed at their 

own pace.  

Participants’ perception of the fit and acceptability of EFT in the context of CPTSD. 

Findings revealed participant experiences regarding the overarching impact, fit, and acceptability 

of EFT for their specific needs of interpersonal trauma-related relationship distress. Specifically, 

EFT served to restructure couples’ ways of relating in order to support emotional safety and co-

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regulation in a way that was trauma-informed, and it was distinctly more beneficial from prior 

experiences of couple therapy that did not use EFT.  

Specifically, analysis revealed that couples experienced relief from getting beyond the 

surface of their negative interactions, which were reinforcing their trauma symptoms of 

difficulties in relationships. This understanding of their core emotions and relational cycle 

further facilitated a pathway for restructuring how couples engaged in their relationship in a way 

that privileged emotional awareness, transparency, and empathy between partners (Johnson, 

2002). This new way of engaging, by attuning to each other’s core emotions and co-regulating, 

was a corrective experience for this sample and allowed them to experience—many of them for 

the first time—emotional safety, even when they were within otherwise fearful states 

(reexperiencing, hypervigilance, etc.). 

In this way, for this particular sample, EFT seemed to have an impact on couples’ 

experiences of trauma symptoms that were related to both exposure and memory-processing 

therapies but that were within the unique context of their intimate relationship (Mahoney et al., 

2019). In exposure and memory-processing therapies, the goal is to shift the traumatic/negative 

association of the trauma stimulus from unsafe to safe by guiding survivors through stages of 

building awareness and corrective emotional experiences where they can establish a way of 

experiencing safety amidst exposure to the trauma stimulus—in this case, close relationships 

(Karatzias et al., 2011; Khalfa & Touzet, 2017; Linder et al., 2022a; 2022b). In their work in 

EFT, rather than being taken over by the intensity of CPTSD symptoms signaling for self-

protection, partners were able to reach outside of fearful symptoms and experience emotional 

attunement and connection. Over time, especially for participants further along in EFT, this 

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allowed couples to experience safety and co-regulation more readily and override their trauma 

symptoms together (Randall et al. 2021). 

In this way, accumulated positive experiences helped partners shift out of their trauma-

related negative beliefs about themselves in relationships and helped them manage symptoms 

that were linked to past interpersonal trauma. Partners described moving from insecure states of 

negative self-concept (i.e., worthlessness, fear of abandonment, etc.) to “I can get close” and “it 

is okay to need my partner.”  

EFT is an intervention intended to treat relational distress. Therefore, there were several 

elements of this analysis that confirmed our typical understanding. One important confirmatory 

element from this study was related to the role of avoidance in couple relationships (Alexander, 

1992; Alexander, 2012; Aloni et al., 2021; Oseland et al., 2016) As demonstrated in chapter 4, 

the CPTSD symptom of avoidance was derived from, and also subsequently impacted, 

relationships. In terms of traumatic stress, the avoidance of trauma stimulus—if the stimulus 

exists within the context of relationships—is very much akin to attachment avoidance (i.e., the 

avoidance of closeness and proximity to attachment figures due to past attachment injuries in 

close relationships). Therefore, it follows that EFT was helpful for CPTSD couples in that the 

intervention directly addressed interpersonal avoidance and moved partners toward vulnerability 

and emotional connection. This experience of connection was viewed as the key ingredient that 

helped couples experience both relief from CPTSD-related distress and a new way of relating 

that sustainably impacted their relationship satisfaction.  

Trauma-informed care in EFT. Though trauma-informed care is not necessarily a core 

feature of the EFT model, participants reported experiencing and valuing the trauma-informed 

care they received from their EFT therapists. Valuable components of care included therapists’ 

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use of the attachment framework to help participants understand their own difficult emotions; 

and therapists’ providing of emotionally attuned care, which involved both validating 

participants’ complex internal experiences and progressing at the client’s pace, which was often 

very slow and gradual. These are key tenants of trauma-informed care (Chouliara et al., 2012), 

and though the EFT model is designed for a general population of couples, it also accounts for 

trauma within couple relationships (Dalton et al., 2014; Johnson, 2002; MacIntosh & Johnson, 

2008; Roundy, 2017). It is apparent that the EFT therapists from this study understood core 

components and the importance of trauma-informed care with interpersonal trauma exposed 

clients.  

Compared to other therapies. Participants experienced EFT as unique, valuable, and 

transformative, especially compared to other prior couple therapies (n=16), though, because it 

was technically relational, it did not address their needs of safety, validation, and emotional 

connection. Therefore, in many cases, it perpetuated their relational distress and worsened their 

CPTSD symptoms.  

EFT facilitated emotional connectedness and safety between partners, which was a new 

way of relating for survivors who expressed a lifetime struggling in close relationships. 

Participants’ experience of EFT was held in stark contrast with their prior participation in couple 

therapy with therapists who did not practice EFT. Couples indicated that their participation in 

prior therapy with therapists who did not practice using EFT had a neutral to negative impact on 

their relationship, in some cases worsening symptoms of relational distress. Conversely, the EFT 

model fit well with trauma survivor couples because it focused on emotional safety between the 

therapist and partners, and interpersonal stabilization (de-escalation) (Cloitre et al., 2011; 

Roundy, 2017). Likewise, EFT’s emphasis of validating difficult emotional experiences was key 

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for participant couples; this is a core feature for interpersonal trauma survivors who often 

experience invalidation from therapists due to the complex inner workings of trauma (Herman, 

1997; Johnson, 2002; Roundy, 2017).  

The findings in this study revealed just how vital the attachment-based mechanisms of 

EFT were for this subgroup of the CPTSD population, which is supported by prior literature with 

PTSD and couples (Blow et al., 2020; Greenman & Johnson, 2012; Karatzias et al., 2018b). 

Indeed, what worked for couples in the context of CPTSD may be similarly useful for those with 

other forms of relational distress. However, it was evident that this population was in desperate 

need of relational intervention, and once they received effective treatment for their relationship 

via EFT with trauma-informed therapists, they were able to experience hope for and relief from 

severe interpersonal trauma symptoms, some for the first time.  

EFT with CPTSD couples: Barriers, critiques, and suggestions. Though this sample 

indicated the strong acceptability of EFT, participants were also able to offer important critiques 

from their experience. A key element was the desire to understand the EFT process and goals 

early on in treatment. Some participants felt their progress was not hindered but somewhat 

delayed because of a lack of clarity in the aims, format, and goals of the EFT treatment model. 

As an attachment-based experiential model, even couples who knew the EFT process found the 

emotionally evocative nature of therapy jarring at first; however, those who were fully aware of 

the process reported a smoother transition and earlier treatment gains. In a similar way, findings 

revealed CPTSD couples expressed discord and discomfort with the idea of a set number of 

sessions for EFT. This finding is in line with prior discussions of trauma intervention in general 

(Karatzias et al., 2019b; Karatzias & Cloitre, 2019), and EFT with trauma populations (Dalton et 

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al., 2014; Greenman & Johnson, 2012); however, it may be important to further explore how to 

discuss treatment planning, goals, and termination with trauma-exposed populations in EFT.  

Another important perspective from this sample was their insight regarding known 

barriers to care for mental health care access and the importance of cohesive care between their 

individual mental health care providers and their EFT therapists. In terms of barriers to care, 

findings revealed the importance of financial and logistical access to not only general mental 

health care but to EFT as an evidence-based systemic intervention for couples in the context of 

traumatic-related interpersonal distress. In terms of logistical barriers, telehealth was one 

solution that participants indicated helped them access EFT (Hogan, 2022). Another issue raised 

within the sample was the relief that they found an effective therapy to address their relational 

needs (Baucom et al., 2014; Stadtmann et al. 2017; 2018), though participants also voiced 

frustration with the amount of time they spent prior to discovering EFT, suffering with ongoing 

interpersonal distress and without effective care. Therefore, findings revealed that access to 

evidence-based systemic care for CPTSD populations is an essential consideration for policy and 

training. Policy, dissemination, and training efforts should focus on expanding access in the 

domains of financial, logistical, clinical training, and developing population awareness of 

attachment-based systemic interventions for CPTSD populations (Collins et al., 2013; Hogan, 

2022; Sareen et al., 2007) 

Finally, some participants indicated their experience of a known and grave issue in 

traumatic stress intervention, which was unethical care for traumatic stress populations (Herman 

1997). Two participant couples reported that once prior therapists learned about the severity of 

client’s traumatic stress symptomology and diagnosis, they terminated or refused treatment and 

did not provide referrals. This unethical dismissal from care based on a client’s diagnosis and 

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their presentation of issues was retraumatizing for participants. Early on in CPTSD 

conceptualization, Herman (1997) outlined the often unethical ways in which some providers 

address cases with difficult trauma presentations, which was unfortunately experienced by some 

in this sample. This again highlights the importance of trauma-informed care and the need to 

expand training and supervision for nonpathologizing, evidence-based interventions.  

Clinical implications. What was unique about this analysis was not that EFT seemed to 

work in a drastically different way for survivors but rather that it was, in fact, acceptable and 

beneficial to them in the context of their CPTSD symptomology. EFT allowed couples, 

especially those with dual CPTSD diagnosis, to experience a sense of calm and co-regulation, 

even amidst their greatest trauma stimulus, the relationship itself (Randall et al., 2021; 

Ruhlmann, 2017). Therefore, perhaps the most important clinical implication for this study is to 

heighten even further the value of attachment-based systemic interventions for treating CPTSD-

specific symptomology and relational distress rooted in interpersonal trauma (Fyvie et al., 2019). 

The depth of impact EFT had on this sample in the light of prior research supports the clinical 

guidelines outlined by Johnson (2002) and Roundy (2017) regarding EFT’s fit as a phased, 

relational intervention for CPTSD-relational distress. The relational conceptualization of CPTSD 

cases must be a central consideration in treatment. Furthermore, as indicated by this sample and 

prior research (Dalton et al., 2014; Greenman & Johnson, 2012; MacIntosh & Johnson, 2008; 

Roundy, 2017), couples seeking treatment in the context of interpersonal trauma can benefit 

from EFT as an emotionally focused, attachment-based, nonpathologizing, experiential 

intervention. However, treatment gains can take months or years to materialize, and clinicians 

must participate in ongoing supervision and training to support their ability to meet the needs of 

high-trauma populations (Coleman et al., 2021). Additionally, individual trauma treatment may 

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be useful or necessary for many cases; therefore, the coordination of care between providers is an 

important consideration to support effective and cohesive treatment for trauma survivors.  

Limitations 

This sample was unique subset of CPTSD and EFT population, which means there were 

aspects of this study that limit the generalizability of the results. Almost all participants met the 

criteria for CPTSD, and all of them had been exposed to interpersonal trauma. Therefore, this 

was a sample of dual trauma couples, which may not represent all relationships. This sample was 

a subgroup of the CPTSD population, as they were all married or in long-term committed 

relationships, which is not considered typical for those with CPTSD (Karatzias et al., 2019a). 

Therefore, these results reflect the experience of highly committed CPTSD couples who likely 

experienced protective factors that supported their ability to maintain their relationship, and 

notably, this sample had access to resources, including individual and couple therapy, which 

helped them cope with CPTSD symptomology. Relatedly, this sample also reported high levels 

of SES and education. Despite recruitment efforts, this sample was also fairly homogeneous in 

terms of race and ethnicity. Future studies should include more diverse samples of CPTSD 

survivors in terms of race and ethnicity, gender identity, and non-Western cultures. Furthermore, 

this study focused on couples in the context of CPTSD who had received effective relational 

treatment; therefore, to understand the broader range of experience of the CPTSD population, 

future studies should include couples who chose to end their relationships due to CPTSD 

symptoms, couples who dropped out of therapy, and couples in other forms of treatment.  

Conclusion  

The findings from this analysis further identify the importance of relational, attachment-

based interventions for CPTSD treatment to meet an essential need and expand effective care for 

175 

 
 
 
this population. The findings from this analysis confirmed prior empirical assumptions and 

expanded upon the theoretical understanding of CPTSD-diagnosed populations and their 

experiences of relationships and EFT as a relational treatment in the context of the diagnosis 

(Dalton et al., 2014; Greenman & Johnson, 2012; Herman, 1997; Karatzias et al., 2018b; Karris 

& Caldwell, 2015; MacIntosh & Johnson, 2008; Roundy, 2017). Making recommendations for 

future studies based on the findings from this study was a core goal of this research, with the aim 

to inform future feasibility and pilot studies using EFT and other attachment-based systemic 

therapies for CPTSD populations based on the outcomes of the data. 

176 

 
 
 
 
 
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APPENDIX A: RECRUITMENT FLYER 

Figure 1 

Recruitment Flyer 

190 

 
 
 
 
APPENDIX B: INFORMED CONSENT FORM 

Study Title: IRB #00006346: The Promise of Attachment-Based Couple Interventions for 
Individuals Living with CPTSD 

Research Participant Information and Consent Form 

Study Title: The Promise of Attachment-Based Couple Interventions for Individuals Living 
with CPTSD  
Researcher and Title: Jennifer VanBoxel, MMFT; Adrian Blow, Ph.D. 
Department and Institution: Human Development and Family Studies, MSU 
Contact Information: 615-308-9474; vanboxe1@msu.edu 

BRIEF SUMMARY 

You  are  being  asked  to  participate  in  a  research  study.  Researchers  are  required  to  provide  a 
consent form to inform you about the research study, to convey that participation is voluntary, to 
explain  risks  and  benefits  of  participation  including  why  you  might  or  might  not  want  to 
participate, and to empower you to make an informed decision. You should feel free to discuss 
and ask the researchers any questions you may have. 

1.  PURPOSE OF THE RESEARCH STUDY 

You are being asked to participate in a research study of couples participating in Emotionally 
Focused Couple therapy(EFT) where one or more partner meets the diagnostic criteria for 
Complex-PTSD. Your participation in this study will take approximately 90 to 120 minutes in 
total. You will be asked to fill out a screening survey and participate in a joint interview with 
your spouse/ significant other that will take 90 to 120 minutes. You are required to continue your 
couples treatment while taking part in this study.  
2.  WHAT YOU WILL DO 

Your participation in this study will involve participating in one 90-to-120-minute joint interview 
with your spouse / significant other. The interview will be audiotaped. The interview will ask 
you and your partner together first about your relationship, your experience of trauma 
symptomology within the relationship based on the ICD-11 C-PTSD diagnosis, and then about 
your experience of Emotionally Focused Couple therapy in the context of those symptoms. The 
online screening survey will ask about general categories of past trauma experienced, but the 
interview will not include any detailed questions about past traumatic events. Further, you may at 
any point skip a question or pause the interview. You will not be expected to discuss any topics 
that make you uncomfortable or do not wish to discuss. Finally, between one and three months 
after the interview is completed you will have the optional opportunity to review initial results 
from the larger study and provide feedback.  

3.  POTENTIAL BENEFITS  

191 

 
 
 
 
 
 
 
  
 
The potential benefits to you for taking part in this study are possible insights from the interview 
discussion into how a traumatic stress diagnosis impacts couple and relationship functioning; such 
insights can be used by participants to integrate into their own therapy as they so choose. Following 
the interview completion participant couples will also receive psychoeducational materials about 
Complex-PTSD  along  with  evidence-based  resources  for  those  with  the  diagnosis.  It  is  also 
possible that you  may not directly benefit from your participation in this study. However, your 
participation in this study may contribute to the understanding of how couples in the context of 
Complex-PTSD experience, manage, and perceive symptoms, which is currently not understood 
by  researchers  and  can  inform  future  treatments  for  Complex-PTSD  populations.  Further,  your 
participation in this study may contribute to the understanding of the fit and acceptability of an 
attachment-based relational intervention (EFT) in treating Complex-PTSD symptomology within 
couple therapy. 

4.  POTENTIAL RISKS 

The major risk of this study is loss of confidentiality. Even though we will not ask your name 
during the interview, there is still a small risk that individuals could identify you because of 
things you describe in your interview. The researchers will try to minimize this risk by deleting 
all audio-recordings after they have been transcribed and deleting any information from 
transcriptions that might allow someone to determine your personal identity. The interviews will 
be typed and stored electronically on password protected computers for analysis by researchers 
on the study team. Ten years after the project closes, they will be permanently deleted. Your 
confidentiality will be protected to the maximum extent allowable by law. 

Certain questions asked in this study may make you feel uncomfortable. The interviewer will ask 
you  about  current  symptoms  of  C-PTSD  and  how  you  may  or  may  not  notice  them  in  your 
relationship in addition to your perspectives on EFT couple treatment. However, the interviewer 
will not ask any in-depth questions about past trauma experienced and will not ask you or your 
partner to disclose any past traumatic experiences in detail. Since this is a joint interview between 
you  and  your  partner  you  may  experience  psychological,  social,  or  personal  distress  from 
discussing trauma symptomology and or experiences of couple therapy with the interviewer in the 
presence of your partner. You are encouraged to process any distressing feelings with your current 
EFT  therapists.  We  will  also  provide  you  with  a  resource  packet  that  will  point  to  additional 
resources you might find useful.  

Participants  are  reminded  that  they  can  share  what  they  are  comfortable  sharing  with  the 
interviewer in the presence of their partner. Further, if a question makes you feel uncomfortable, 
you are free to skip that question. Individuals conducting the interviews are mandated reporters 
and are required by Michigan law to report to authorities if someone discloses their intent to harm 
self or others. If we suspect a child is or may be abused or neglected, we must contact Children’s 
Protective Health Services immediately.  

5.  PRIVACY AND CONFIDENTIALITY  

192 

 
 
 
 
 
 
 
 
Your decision to participate is completely at your discretion and you are free to discuss the issue 
of participation with your partner, your therapist, and with others outside your family unit at your 
discretion. Involvement in this study may result in a loss of privacy since your partner and 
research staff may be aware of your participation. Information about you will be kept 
confidential to the maximum extent allowable by law. All research staff are required to keep 
your personal information private. Your responses to all questions will be confidential and stored 
in a secure manner. At no time will identifiable information be stored with your interview. You 
are free to decline to answer any specific question.  

The interview will be audiotaped as a part of participation in the project. The interview will be 
transcribed, during which all identifying information will be deleted from the transcribed 
interview and after that, the audio recording will be deleted.  

All research data collected as part of this study will be stored according to the privacy and 
security guidelines established by the Institutional Review Boards of participating organizations. 
Paper copies will be locked in filing cabinets in locked offices of the study team. Only 
authorized research staff will have access to study data. Members of the research team will 
analyze the data collected from this study. The results of this study may be published in scholarly 
journals or presented at scientific meetings, but participants’ names will never be mentioned.  

If you indicate interest in future surveys and supply information regarding your telephone and 
email address, you may be contacted about additional studies by means of the contact 
information you provide today.  

The following individuals will have access to the data: 

•  Researchers and Research Staff. 
• 
• 

Institutional Review Board (IRB) personnel should they choose to audit the study. 
In all cases, identifying information will not be stored with or connected to study data. 

6.  YOUR RIGHTS TO PARTICIPATE, SAY NO, OR WITHDRAW  

Participation  is  voluntary.  Refusal  to  participate  or  discontinue  participation  will  involve  no 
penalty or loss of benefits to which you are otherwise entitled. You have the right to say no. You 
may change your mind at any time and withdraw. You may choose not to answer specific questions 
or to stop participating at any time. If you withdraw, your responses from previous participation 
will remain in the study.  

7.  COSTS AND COMPENSATION FOR BEING IN THE STUDY 

193 

 
 
 
 
 
 
 
 
 
 
 
There are no costs to your participation in the study. You and the other adult in your couple 
relationship, 18 years of age and older will each receive a $50 Amazon.com gift certificate for 
participation in the 90 minute interview. 

8.  ALTERNATIVE OPTIONS  

You may choose not to participate in the study. 

9.  CONTACT INFORMATION  

If you have concerns or questions about this study, such as scientific issues, how to do any part 
of it, or to report an issue, please contact either researcher: Jennifer VanBoxel, LMFT, via phone 
(615)308-9474, or Email jennifervanboxel@gmail.com, or vanboxe1@msu.edu, or Adrian Blow, 
PhD 7 Human Ecology, Michigan State University, (517) 355-0230 or Email: blowa@msu.edu. 

If you have questions or concerns about your role and rights as a research participant, would like 
to obtain information or offer input, or would like to register a complaint about this study, you 
may contact, anonymously if you wish, the Michigan State University’s Human Research 
Protection Program at 517-355-2180, Fax 517-432-4503, or e-mail irb@msu.edu or regular mail 
at 4000 Collins Rd, Suite 136, Lansing, MI 48910. 

By proceeding and completing the interview, you are voluntarily consenting to participate in this 
project and have your responses included in the study. 

10. DOCUMENTATION OF INFORMED CONSENT  

Your signature below means that you voluntarily agree to participate in this research study.  

________________________________ 
Signature 

________________________ 

Date 

You will be given a copy of this form to keep. 

11.  RECORDING CONSENT  

▪ 

I agree to allow audiotaping/videotaping of the interview. 

 Yes 

 No  

Initials____________ 

194 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
APPENDIX C: CLIENT SCREENING SURVEY 

MSU - C-PTSD & EFT Study 

Participant Eligibility Screening  

This is a brief survey for the Emotionally Focused Couple therapy (EFT) and Complex-PTSD 
research study. Once your response is scored you will receive an email regarding your eligibility 
for the study.  

This survey includes several general questions regarding your current participation in Therapy. 
You will also be asked to complete and the International Trauma Questionnaire.  

Please note that eligibility for the study includes that you are your partner are participating in 
EFT couple therapy and that one or both partners meet the diagnostic criteria for Complex-
PTSD. Please contact the study organizer with any questions at:  
eftandcomplexptsdstudy@gmail.com  

Intro 2 Please write your name and email address:  
Note* this address will only be used to inform you about the results of the survey regarding 
study eligibility 

________________________________________________________________ 

Intro 3 I consent to receiving email contact regarding my eligibility for the study 

o Yes (1)  

o No (2)  

Intro 4 Please list your partner’s full name who is participating with you in couple therapy and 
who will also take this eligibility survey  
Note* this information will only be used to determine final eligibility for the study when both 
partners have completed the survey  

________________________________________________________________ 

195 

 
 
 
 
 
 
 
 
 
 
EFT 1 Are you and your partner currently in couple therapy with an Emotionally Focused 
Couples therapist?  

o Yes (1)  

o No (2)  

o Not sure (3)  

o Not currently, but we ended/ completed treatment (4)  

EFT 2 Please list the name and practice information for your current / most recent EFT Couples 
Therapist_____________________________________________________________________ 
Note: Therapists will not be contacted. This information will be used to determine therapist 
qualifications for the study  
EFT 3 If you are currently participating in couples therapy, or if you have completed treatment 
please estimate how many sessions you have had with your current or most recent couples 
therapist  

o 1-8 (1)  

o 8-16 (2)  

o 17-24 (3)  

o 25-51 (4)  

o 52 or more (5)  

ITQ Information: The next six questions are a part of the International Trauma Questionnaire 
(ITQ) PTSD & Complex-PTSD screening.  
ITQ will ask two brief questions about past traumatic experiences and 18 Likert scaled questions 
about ongoing traumatic stress symptoms.  
ITQ - Experience Instructions: Please identify the experience that troubles you most and answer 
the questions in relation to this experience. Brief description of the 
experience:  ________________________________________________________________ 
ITQ - Time When did the experience occur? (Click one) 

196 

 
 
 
o less than 6 months ago (1)  

o 6 to 12 months ago (2)  

o 1 to 5 years ago (3)  

o 5 to 10 years ago (4)  

o 10 to 20 years ago (5)  

o more than 20 years ago (6)  

ITQ - PTSD I Below are a number of problems that people sometimes report in response to 
traumatic or stressful life events. Please read each item carefully, then circle one of the numbers 
to the right to indicate how much you have been bothered by that problem in the past month. 

197 

 
 
 
 
P1. Having 
upsetting dreams 
that replay part of 
the experience or are 
clearly related to the 
experience? (1)  

P2. Having powerful 
images or memories 
that sometimes 
come into your mind 
in which you feel 
the experience is 
happening again in 
the here and now? 
(2)  

P3. Avoiding 
internal reminders 
of the experience 
(for example, 
thoughts, feelings, 
or physical 
sensations)? (3)  

P4. Avoiding 
external reminders 
of the experience 
(for example, 
people, places, 
conversations, 
objects, activities, or 
situations)? (4)  

P5. Being “super-
alert”, watchful, or 
on guard? (5)  

P6. Feeling jumpy 
or easily startled? 
(6)  

Not at 
all (0) 

A little 
bit (1) 

Moderately 
(2) 

Quite a 
bit (3) 

Extremely 
(4) 

o   o  

o  

o  

o  

o   o  

o  

o  

o  

o   o  

o  

o  

o  

o   o  

o  

o  

o  

o  

o  

o  

o  

o   o  

o   o  

o  

o  

198 

 
 
 
 
 
ITQ PTSD II In the past month have the above problems: 

Not at all (0) 

A little bit (1)  Moderately (2)  Quite a bit (3) 

Extremely (4) 

o  

o  

o  

o  

o  

o  

o  

o  

o  

o  

o  

o  

o  

o  

o  

P7. Affected 
your 
relationships or 
social life? (1)  

P8. Affected 
your work or 
ability to 
work? (2)  

P9. Affected 
any other 
important part 
of your life 
such as 
parenting, or 
school or 
college work, 
or other 
important 
activities? (3)  

ITQ C-PTSD: Below are problems that people who have had stressful or traumatic events 
sometimes experience. The questions refer to ways you typically feel, ways you typically think 
about yourself and ways you typically relate to others. Answer the following thinking about how 
true each statement is of you. 

199 

 
 
 
 
 
 
How true is this of you? 

Not at all (0) 

A little bit (1)  Moderately (2)  Quite a bit (3) 

Extremely (4) 

C1. When I am 
upset, it takes 
me a long time 
to calm down. 
(1)  

C2. I feel 
numb or 
emotionally 
shut down. (2)  

C3. I feel like a 
failure. (3)  

C4. I feel 
worthless. (4)  

C5. I feel 
distant or cut 
off from 
people. (5)  

C6. I find it 
hard to stay 
emotionally 
close to 
people. (6)  

o  

o  

o  

o  

o  

o  

o  

o  

o  

o  

o  

o  

o  

o  

o  

o  

o  

o  

o  

o  

o  

o  

o  

o  

o  

o  

o  

o  

o  

o  

ITQ C-PTSD II In the past month, have the above problems in emotions, in beliefs about 
yourself and in relationships: 

200 

 
 
 
 
Not at all (0)  A little bit (1)  Moderately (2)  Quite a bit (3)  Extremely (4) 

o  

o  

o  

o  

o  

o  

o  

o  

o  

o  

o  

o  

o  

o  

o  

C7. Created 
concern or 
distress about 
your 
relationships 
or social life? 
(1)  

C8. Affected 
your work or 
ability to 
work? (2)  

C9. Affected 
any other 
important parts 
of your life 
such as 
parenting, or 
school or 
college work, 
or other 
important 
activities? (3)  

End of Block: ITQ - 5 minutes  

Start of Block: Post ITQ Info 

Post 1 If you experienced these symptoms prior to receiving EFT couple therapy and have reason 
to believe couple therapy treated these symptoms for you, please indicate below. If not, type N/A 

________________________________________________________________ 

Post 1: Thank you for taking the EFT & C-PTSD couples screening survey!  
Once you complete the survey you will receive an email within the next 24 hours to inform you 
if you might qualify the study. Once you and your partner complete the survey you will each 
receive notice if you qualify as a couple to participate.  

201 

 
 
 
 
 
 
 
 
 
The study organizer will contact you regarding next steps in final consent and interview 
scheduling. Thank you so much for your participation! 

Post 2: Would you feel comfortable participating in a joint interview with your partner to discuss 
how you experience couple therapy and also to discuss how you experience C-PTSD symptoms 
(your partner’s and/or your own) within your relationship?  
Note* the interview will be taken with a trauma informed, couples therapist and will not address 
past trauma, but focus on learning from you and your partner to help better inform future 
therapeutic intervention.  

Additionally, the interview will seek to be supportive and offer insight and resources for couples 
who manage C-PTSD within their relationship. You are welcome to contact the study organizer 
at : vanboxe1@msu.edu to learn more and gauge your comfort level about participating in the 
join couples interview.  

o Yes (1)  

o Maybe, but I would like to learn more (2)  

o No, I would not feel comfortable (3)  

End of Block: Post ITQ Info 

202 

 
 
 
 
 
 
 
 
 
 
APPENDIX D: DEMOGRAPHIC SURVEY 

CPTSD & EFT Study Demographic Survey 

Start of Block: Demographics & Consent to Schedule 

Please enter your name: 

________________________________________________________________ 

Q0 Gender Identification:  

________________________________________________________________ 

Q1 Please list your sexual orientation  

________________________________________________________________ 

203 

 
 
 
 
 
 
Q2 Age 

o 18-24  

o 25-34  

o 35-44  

o 45-54  

o 55-64  

o 65+  

Q3 Relationship Status. Please mark all that apply  

▢ 

▢ 

▢ 

▢ 

▢ 

▢ 

Married  

Widowed  

Divorced  

Separated  

Not married  

Engaged  

204 

 
 
 
 
▢ 

▢ 

In a committed relationship  

Other  

Q4 Length of time in current relationship 

________________________________________________________________ 

Q5 Please list how many children you have, if any  

o None  

o 1 child  

o 2-3 children  

o 4-5 children  

o 6-7 children  

o 8 or more children  

Q6 Employment  

o Full-time  

o Part-time  

o Unemployed/ retired  

205 

 
 
 
 
 
 
Q7 Highest level of education 

o Some high school/ or other  

o Technical school  

o Some college  

o College Degree  

o Graduate/ Masters Degree  

o Doctorate Degree  

Q8 Annual household income 

o Less than US $20,000  

o US$20,000 - US$39,000  

o US$40,000 - US$59,000  

o US$60,000 - US$79,000  

o US$80,000 - US$99,000  

o US$100,000 or higher  

206 

 
 
 
 
 
Q9 Ethnicity  

▢ 

▢ 

▢ 

▢ 

▢ 

▢ 

▢ 

▢ 

White / Caucasian  

Black or African American  

American Indian and Alaska Native  

Asian  

Native Hawaiian or Other Pacific Islander  

Hispanic of Latino  

Middle Eastern  

Other  

Q10 Please list where are you located (country, state) 

________________________________________________________________ 

207 

 
 
 
 
Q11 I would like to schedule the joint interview for the study. In doing so I offer permission to 
the study team to email me and my partner in a joint email to schedule the interview and send the 
informed consent form for the study. 

o Yes, I would like to schedule the joint interview and offer permission to email me and my 

partner  

o Maybe, but I would like to discuss further via email  

o Maybe, I would like to discuss further via zoom meeting  

o I would not like to participate in the study at this time  

Q12 Please list both your email and your partner’s email in the field below  

________________________________________________________________ 

End of Block: Demographics & Consent to Schedule 

208 

 
 
 
 
 
 
 
APPENDIX E: THERAPIST SCREENING QUESTIONNAIRE 

EFT Therapist Eligibility for C-PTSD Research Study 

Start of Block: Default Question Block 

EFT 1a  
To participate as an eligible EFT therapist for this cutting edge intervention study please answer 
the following 9 questions:  

First, please enter your 1) Full name & license type (e.g., LPC, LMFT, LMSW) 

________________________________________________________________ 

EFT 1b 2) Email address 
Note* you will not be contacted or added to any contact list unless you opt in at the end of the 
survey. 

________________________________________________________________ 

EFT 1c 3) Practice location (full work address, or - city/state in which you practice)  

________________________________________________________________ 

EFT 1d: 4) Professional website URL (if available) 

________________________________________________________________ 

209 

 
 
 
 
 
 
 
 
EFT 2: Do you consider yourself an Emotionally Focused Couples Therapist? (i.e., do you 
conduct therapy with couples using the EFT model? ) 

o Yes, I have been trained and implement the EFT model with client couples  

o Mostly, I have been trained and usually use EFT with client couples  

o A little bit, I have been trained to a degree and try to use some EFT principles in my work 

with couples  

o Not really, I know about EFT, but I have not been professionally trained and I am unsure 

if I am using EFT with client couples  

o No, I have not been trained in EFT and I do not use it in therapy  

EFT 3: Please indicate the highest level of training have you received for Emotionally Focused 
Couples Therapy?  

o EFT Externship  

o EFT Core Skills 1  

o EFT Core Skills 2  

o EFT Core Skills 3  

o EFT Core Skills 4  

o EFT - post core skills continuing education / consultation groups  

o EFT Certification  

210 

 
 
 
o EFT Trainer  

EFT 4: Are you willing to distribute study information to your clients either via email or posted 
in your office? Please note: if you check yes, or maybe you will receive the study flyer via email 
along with guidelines about how you can share this opportunity with your clients. 

o Yes, I am prepared to share study information with my clients  

o Maybe, but I would like to learn more about the guidelines  

o No, I would not like to receive additional information about this study  

EFT 5: If you have questions about this process, please enter them here, and the study organizer 
will respond to your questions via email.  

________________________________________________________________ 

EFT 6: If you would like to meet with the study organizer via email, phone, or zoom meeting to 
learn more please indicate:  

o Yes, I would like more information via email  

o Yes, I would like to discuss more about the study briefly over the phone  

o Yes, I would like to meet via zoom to learn more about the study  

o No, I do not need more information  

211 

 
 
 
 
 
 
 
EFT 7: If eligible to participate as an EFT therapist for this study, would you like to receive an 
acknowledgment in the published manuscript of this EFT intervention study?  

o Yes  

o Maybe  

o No  

EFT 8: If you answered ‘yes’, or ‘maybe,’ please enter your name and contact information again, 
and you will be contacted prior to publication for a final approval to add your name to the 
published acknowledgments for this EFT Intervention study.  

________________________________________________________________ 

EFT 9: If you know of other EFT therapists who might be eligible for this study, you can either 
send them the study website and/or add their contact information below  

________________________________________________________________ 

212 

 
 
 
 
 
 
 
APPENDIX F: INTERNATIONAL TRAUMA QUESTIONNAIRE 

THE INTERNATIONAL TRAUMA QUESTIONNAIRE (ITQ)  
OVERVIEW: 
The attached instrument 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. The ITQ is freely available in the public domain to all interested parties. Evaluation of the 
measure continues particularly as it relates to the definition of functional impairment for both PTSD and 
CPTSD and possibly the content of the items as they might relate to being predictive of differential 
treatment outcome.  
DIAGNOSTIC ALGORITHMS are as follows: 
PTSD. A diagnosis of PTSD requires the endorsement of one of two symptoms from the symptom 
clusters of (1) re- experiencing in the here and now, (2) avoidance, and (3) sense of current threat, plus 
endorsement of at least one indicator of functional impairment associated with these symptoms. 
Endorsement of a symptom or functional impairment item is defined as a score > 2.  
CPTSD. A diagnosis of CPTSD requires the endorsement of one of two symptoms from each of the three 
PTSD symptoms clusters (reexperiencing in the here and now, avoidance, and sense of current threat) and 
one of two symptoms from each of the three Disturbances in Self-Organization (DSO) clusters: (1) 
affective 
dysregulation, (2) negative self-concept, and (3) disturbances in relationships. Functional impairment 
must be identified where at least one indicator of functional impairment is endorsed related to the PTSD 
symptoms and one indicator of functional impairment is endorsed related to the DSO symptoms. 
Endorsement of a symptom or functional impairment item is defined as a score > 2.  
An individual can receive either a diagnosis of PTSD or CPTSD, not both. If a person meets the criteria 
for CPTSD, that person does not also receive a PTSD diagnosis.  
Scoring instructions are available at the end of this document.  

213 

 
 
 
 
 
Figure 2  

International Trauma Questionnaire 

214 

 
 
 
 
Figure 2 (cont’d) 

215 

 
 
 
 
 
 
1. Diagnostic scoring for PTSD and CPTSD  

PTSD  

If P1 or P2 > 2 criteria for Re-experiencing in the here and now (Re_dx) met If P3 or P4 > 2 criteria for 

Avoidance (Av_dx) met 

If P5 or P6 > 2 criteria for Sense of current threat (Th_dx) met 

AND  

At least one of P7, P8, or P9 > 2 meets criteria for PTSD functional impairment (PTSDFI) 

If criteria for ‘Re_dx’ AND ‘Av_dx’ AND ‘Th_dx’ AND ‘PTSDFI’ are met, the criteria for PTSD are 

met.  

CPTSD  

If C1 or C2 > 2 criteria for Affective dysregulation (AD_dx) met 

If C3 or C4 > 2 criteria for Negative self-concept (NSC_dx) met 

If C5 or C6 > 2 criteria for Disturbances in relationships (DR_dx) met 

AND 

At least one of C7, C8, or C9 > 2 meets criteria for DSO functional impairment (DSOFI) 

If criteria for ‘AD_dx’ AND ‘NSC_dx’ AND ‘DR_dx’, and ‘DSOFI’ are met, the criteria for DSO are 

met.  

PTSD is diagnosed if the criteria for PTSD are met but NOT for DSO. 

CPTSD is diagnosed if the criteria for PTSD are met AND criteria for DSO are met. 

Not meeting the criteria for PTSD or meeting only the criteria for DSO results in no diagnosis.  

2. Dimensional scoring for PTSD and CPTSD.  

Scores can be calculated for each PTSD and DSO symptom cluster and summed to produce PTSD and 

DSO scores.  

PTSD  

Sum of Likert scores for P1 and P2 = Re-experiencing in the here and now score (Re) Sum of Likert 

scores for P3 and P4 = Avoidance score (Av) 

216 

 
 
 
Sum of Likert scores for P5 and P6 = Sense of current threat (Th) 

PTSD score = Sum of Re, Av, and Th  

DSO  

Sum of Likert scores for C1 and C2 = Affective dysregulation (AD) 

Sum of Likert scores for C3 and C4 = Negative self-concept (NSC) 

Sum of Likert scores for C5 and C6 = Disturbances in relationships (DR) DSO score = Sum of AD, NSC, 

and DR  

217 

 
 
 
 
 
 
APPENDIX G: SEMI-STRUCTURED INTERVIEW GUIDE 

Introduction  

Today I will be asking questions about your relationship, your experience of trauma 

symptomology within the relationship, and your experience of Emotionally Focused Couples 

Therapy. Today’s discussion will not include any questions about past traumatic events, 

however, please let me know at any point if you would like to skip a question or pause the 

interview.  

General/ historical view of current relationship:  

To begin I am going to ask a few general questions about your relationship. I will ask each of 

you the same questions in an alternating fashion to ensure equal time.  

o  How long have you known each other and/or been together as a couple?  

o  How would you describe the beginning/ early stages of your relationship?  

o  How would you characterize your current relationship? 

o  What are your hopes for your relationship in the future?  

PTSD & Relational Experience:  

I am going to ask some questions pertaining to your experience of certain traumatic stress 

symptoms within the relationship. 

• 

(Avoidance 1) Some people who have experienced trauma may avoid certain external 

reminders including people, places, conversations, objects, activities or situations: 

o  (Experience) Within the context of your relationship do you notice that either you or 

your partner seem to avoid certain external reminders in this way?  

▪ 

(Perceive): If so: how do you perceive or notice when this is happening? 

218 

 
 
 
▪ 

(Manage): If so: what do you notice that you and your partner do when this is 

happening? 

• 

(Avoidance 2) Some people who have experienced trauma may avoid certain internal 

reminders including thoughts, feelings, or physical sensations: 

o  (Experience) Within the context of your relationship do you notice that either you or 

your partner seem to avoid certain internal reminders in this way?  

▪ 

▪ 

(Perceive): If so: how do you perceive or notice when this is happening? 

(Manage): If so: what do you notice that you and your partner do when this is 

happening? 

• 

(Hypervigilance 1) Some people who have experienced trauma may notice that they are often 

‘super-alert,’ watchful, or on guard as though something bad might happen and they need to 

be on the lookout and/or prepare for the worst.  

o  (Experience) Within the context of your relationship do you notice that you or your 

partner seem to be super-alert or on guard in this way? 

▪ 

▪ 

(Perceive): If so: how do you perceive or notice when this is happening? 

(Manage): If so: what do you notice that you and your partner do when this is 

happening? 

• 

(Hypervigilance 2) Some people who have experienced trauma may notice that they are often 

easily startled or jumpy.  

o  (Experience) Within the context of your relationship do you notice that you or your 

partner seem to be easily startled or jumpy in this way? 

▪ 

(Perceive): If so: how do you perceive or notice when this is happening? 

219 

 
 
 
▪ 

(Manage): If so: what do you notice that you and your partner do when this is 

happening? 

• 

(Reexperiencing 1) Some people who have experienced trauma may notice powerful images 

or memories come to mind that are so strong it feels like the experience is happening again in 

the here and now. 

o  (Experience) Within the context of your relationship do you notice that you or your 

partner at times experience powerful images or memories that seem like they are 

replaying in the present moment?  

▪ 

▪ 

(Perceive): If so: how do you perceive or notice when this is happening? 

(Manage): If so: what do you notice that you and your partner do when this is 

happening? 

• 

(Reexperiencing 2) Some people who have experienced trauma may have upsetting dreams 

that replay part of a difficult or traumatic experience or are clearly related to the experience. 

o  (Experience) Within the context of your relationship do you notice that you or your 

partner have upsetting dreams that are either related to or replay difficult or traumatic 

experiences?  

▪ 

▪ 

(Perceive): If so: how do you perceive or notice when this is happening? 

(Manage): If so: what do you notice that you and your partner do when this is 

happening? 

DSO & Relational Experience:  

• 

(Emotion regulation difficulties 1) Some people who have experienced trauma may 

experience that it takes a long time to feel calm after getting upset.  

220 

 
 
 
o  (Experience) Within the context of your relationship do you notice that you or your 

partner struggle to regain a state of calm after getting upset? 

▪ 

▪ 

(Perceive): If so: how do you perceive or notice when this is happening? 

(Manage): If so: what do you notice that you and your partner do when this is 

happening? 

• 

(Emotion regulation difficulties 2) Some people who have experienced trauma may 

experience feeling numb or emotionally shut down (i.e., cut off from your own emotions).  

o  (Experience) Within the context of your relationship do you notice that you or your 

partner struggle by feeling numb or emotionally shut down? 

▪ 

▪ 

(Perceive): If so: how do you perceive or notice when this is happening? 

(Manage): If so: what do you notice that you and your partner do when this is 

happening? 

• 

(Negative View of Self 1) Some people who have experienced trauma may struggle with 

chronic negative beliefs about themselves: for example, ‘I feel like a failure’, or ‘I feel 

worthless.’ 

o  (Experience) Within the context of your relationship do you notice that you or your 

partner struggle with these or other related negative beliefs?  

▪ 

▪ 

(Perceive): If so: how do you perceive or notice when this is happening? 

(Manage): If so: what do you notice that you and your partner do when this is 

happening? 

• 

(Negative View of Self 2) Some people who have experienced trauma may struggle with 

chronic negative beliefs about themselves: for example, ‘I feel distant of cut-off from 

people’, or ‘I find it hard to stay emotionally close to people.’  

221 

 
 
 
o  (Experience) Within the context of your relationship do you notice that you or your 

partner struggle with these or other related negative beliefs? 

▪ 

▪ 

 (Perceive): If so: how do you perceive or notice when this is happening? 

(Manage): If so: what do you notice that you and your partner do when this is 

happening? 

• 

(Disturbances in relationship 1) Some people who experience the prior mentioned symptoms 

(provide a reminder if needed) may also notice that these have either created a concern 

within the relationship or affect their relationship directly in some way?  

o  (Experience) Within the context of your relationship do you notice that any of the 

mentioned symptoms have created concern or have directly affected your 

relationship?  

▪ 

▪ 

(Perceive): If so: how do you perceive or notice how this is the case? 

(Manage): If so: what do you notice that you and your partner do to address 

this issue or concern? 

• 

(Disturbances in relationship 2) Some people who experience the prior mentioned symptoms 

(provide a reminder if needed) may also notice that these have affected them in terms of 

work, parenting, school, or other important activities?  

o  (Experience) Within the context of your relationship do you notice that you or your 

partner have been affected regarding work, school or important activities by the prior 

mentioned symptoms? 

▪ 

▪ 

(Perceive): If so: how do you perceive or notice how this is the case? 

(Manage): If so: what do you notice that you and your partner do to address 

this issue or concern? 

222 

 
 
 
• 

(Disturbances in relationship 3 - open-ended) Is there anything else you would like to share 

from your perspective regarding how past trauma experiences and current trauma symptoms 

impact your relationship?  

Experience of Emotionally Focused Couple therapy 

Now I am going to shift and ask a few questions regarding your experience so far in Emotionally 

Focused Couple therapy(EFT).  

General 

o  Why did you first seek EFT couples therapy? 

o  How long have you been in EFT? 

o  Have you been in couple therapy together before? 

o  Prior to starting what do you hope to gain from EFT?  

Symptomology Specific 

o  Given the context of our conversation today regarding trauma symptoms (provide a 

reminder if needed):  

▪  Do you feel EFT couple therapy has addressed any of the above-mentioned 

symptoms and issues within the context of your relationship? How so? 

If anything, what do you find helpful from EFT couple therapy so far? 

If anything, what does your therapist do that is helpful for you and /or your 

relationship?  

If anything, what has been especially difficult about EFT couples therapy? 

If anything, what does your therapist do that is not helpful for you and/or your 

▪ 

▪ 

▪ 

▪ 

relationship? 

223 

 
 
 
 
▪ 

Is there anything that you do not like or do not find helpful about EFT couple 

therapy so far? 

•  Are there parts of EFT that you feel are barriers to reaching the goals 

you have for your relationship in therapy?  

▪  Have there been any changes in your relationship since starting EFT couples 

therapy?  

•  What has changed for you individually since starting EFT?  

o  Do you feel EFT couple therapy is or will be effective for you as a couple? How or 

how not?  

o  What do you want therapists to know about how they can help couples like you?  

Closing & Debriefing  

Thank you for your time and participation in this interview. I will now ask a few final questions 

about what it was like participating in this interview today and also provide some additional 

resources.  

o  What was it like to participate in this interview?  

▪  What was it like to have this discussion together with your partner present? 

o  Do you feel this conversation will impact your next/subsequent therapy sessions?  

o  Do you feel like you can talk to your EFT therapist about what came up in the 

interview today?  

**Provide resources**  

Thank you…

224 

 
 
 
 
APPENDIX H: STUDY ONE—FRAMEWORK MATRIX 

Table 3  

Framework Matrix 

Symptom Category 

Avoidance 

Experience 

Relational Impact   

Management & Coping 

Theme  

 Couples 
consistently 
avoided relational 
trauma stimuli 
within their 
relationship   

Avoidance related 
withdrawal and 
disassociation led 
to distance and 
disconnection 
between partners  

 Mutual activation 
of avoidance 
symptoms between 
partner. 

 Avoidance of 
emotional and 
sexual intimacy. 

Lack of resolution with avoidance 
symptoms  

Discovering and 
understanding 
avoidance within 
the relationship is a 
process  

Summary  

Conscious and 
unconscious 
avoidance of 
certain ways of 
connecting or 
interacting within 
the context of the 
couple relationship 
due to prior trauma 
stimulus that exists 
within the context 
of relationship  

Experiencing 
something that 
relates to a 
relational trauma 
stimulus within the 
context of the 
relationship that 
leads to protective 
behaviors of 
disassociation and 
withdrawal that 
widen the gap of 
connection within 
the relationship  

Avoidance from 
one’s partner 
activating 
individual’s 
avoidance 
(emotional 
detachment)  

Partners avoiding 
past interpersonal 
trauma triggers via 
emotional or sexual 
intimacy   

Difficulty and lack of resolution 
managing avoidance and subsequent 
disconnection within the relationship  

Continual 
progression toward 
learning about the 
symptom of 
avoidance and its 
origins for each 
partner while 
building mutual 
empathy when it 
arises  

225 

 
 
 
 
 
 
 
 
Table 3 (cont’d) 

Symptom Category 

Hypervigilance  

Theme 

A way of being in relationship  

Pervasive fear and distress 
within the relationship 

Defensiveness, fear, and being on 
guard toward partners and the 
relationship  

Mutual awareness and 
emotional connection  

Experience 

Relational Impact   

Management & Coping 

Summary  

Like a constant hum in the 
background, or a preprogramming of 
waiting for something bad to happen 
within the relationship: a constant 
state of alert &/or also sudden 
extreme fear responses  

Complex and pervasive 
automated sense of threat related 
to their intimate relationship 
and/or partner (being afraid of 
something bad happening to them 
within the context of their 
relationship [i.e., abandonment, 
neglect, control, loss, or 
betrayal]).  

Negative impact of invasive 
thoughts: thinking the worst 
when it comes to the relationship 
based on past experience. This 
fearful and relationally 
hypervigilant state is distressing 
for couples: sparking negative 
circular interactions of 
defensiveness, fear, and blame, 
and being "on alert" towards and 
against one's partner guarding 
against something really severe 
constantly  

Mutual empathy and skills 
related to mindful acceptance 
and emotional awareness 
related to hypervigilance in 
the relationship were key. 
Partners' mutual awareness of 
hypervigilance and its origins 
from prior trauma directly fed 
into a couples’ ability to 
redirect and reflect on what is 
driving fear and conflict 
within the relationship 

Symptom Category 

Reexperiencing  

Experience 

Relational Impact   

Management & Coping 

Theme  

 Reexperiencing was intrusive and 
impaired cohesion in the relationship  

Relational reexperiencing 

Relational impact of 
reexperiencing: The unique 
impact of the couple relationship 
as trauma stimulus 

Reexperiencing: Management 
and coping—process of 
identification and discernment 
between past and the present 

226 

 
 
 
 
 
 
 
 
 
 
 
 
Table 3 (cont’d) 

Summary  

Partners describing reexperiencing as 
a pervasive, invasive, and highly 
distressing symptom individually & 
within the relationship 

Reexperiencing was both 
tangible (like images or specific 
memories) and intangible (more 
like a feeling) or a filter from the 
past for the present moment 
within the relationship 

The impact of reexperiencing 
interpersonal trauma within the 
context of the current relationship 
meant: partners responding to 
what was and not what is (and 
being confused between the two 
and often disassociated or 
reactive when this was 
happening)  

Managing reexperiencing 
required a lot of effort: 
Partners helped each other 
identify and discern 
reexperiencing signals of 
disassociation and reactivity 
via recognizing its harmful 
pattern and impact on the 
relationship and pausing and 
being mindful to identify 
where the intense signals were 
coming from and redirecting  

Symptom Category 

Negative Self-Concept  

Experience 

Relational Impact   

Management and Coping  

Theme 

Negative and/or defeating 
internal experiences of 
themselves in relationship to 
their partners 

Emotional distance 
and disconnection 
between partners  

Negative 
Relational Concept  

A mutually activating 
cycle 

Extensive intentional 
effort and resourcing 

Identification, 
partner awareness, 
and safety to be 
vulnerable 

227 

 
 
 
 
 
 
 
 
 
Table 3 (cont’d) 

Summary  

Deeply healed beliefs that 
they will never be safe, 
enough, or are failing that 
relate to their intimate 
relationship creating a harsh, 
and critical internal and 
relational environment   

The negative self-
concept leads to 
emotional 
disconnection or 
shut down between 
partners because 
they do not trust 
they are or can be 
secure, loved, or 
accepted on a deep 
level and 
emotionally turn 
away from their 
partners 

Experiencing the 
relationship from 
an investable belief 
of being defeated 
and unsafe, 
unwanted, or 
unaccepted  

Negative beliefs 
creating an 
unintentionally hostile 
environment within the 
relationship (and harm 
towards partners) that 
was mutually 
activating of their 
negative self-concepts  

Individual therapy and 
external supported 
reported which aided 
in individual 
management of 
negative self-concept 
beliefs  

Individual and 
partner awareness, 
and the emotional 
safety that allowed 
them to be 
vulnerable with 
each other 

Symptom Category 

Emotion Regulation Difficulties  

Experience 

Relational Impact   

Management & Coping 

Theme 

Reactive cycles of emotional constriction 
and hyperactivation.  

Chronic negative emotional experiences 
between partners.  

Partners discerned and expressed needs 
for individual and co-regulation.  

Summary  

Symptoms of fearful reactivity and anger 
(hyperactivation), or emotional avoidance 
(hypoactivation) such as emotional cutoffs 
and disassociation, played a significant 
role in couple dynamics and 
communication 

Consistent emotion-regulation difficulties 
within the relationship instilled a negative 
cycle between partners in which fearful 
states related to past trauma interrupted the 
current dynamics of the couple 
relationship 

Coping with strong emotions with 
resulting reactivity or numbing was 
difficult for partners to attain; however, 
they described how combined efforts to 
emotionally regulate both individually 
and together were key 

Symptom Category 

Difficulties in Relationship  

Experience 

Relational Impact   

Management & Coping 

228 

 
 
 
 
 
 
 
 
 
 
 
 
Table 3 (cont’d) 

Theme 

Trauma was a filter for how 
partners experienced close 
relationships  

Interpersonal 
trauma impact: as 
a degenerative, 
invasive, and 
harmful third 
entity in the 
relationship. 

Relational impact 
disturbance in 
relationships: 
Polytraumatization 
and relational 
layers of 
complexity.  

Coping: building 
mutual awareness of 
individual 
interpersonal trauma 
symptoms within the 
relationship 

Understanding and 
identifying trauma 
while developing 
mutual support.  

Summary 

Relationships are triggering: 
Painful, complex, or difficult 
experiences within their 
relationship, which were 
linked to intrusive symptoms 
derived from past 
interpersonal trauma  

The role of trauma 
was like an 
uncontrollable 
third person in the 
relationship that 
caused havoc and 
broke down 
relationships 
leading to extreme 
distress especially 
in the context of 
transition or 
additional stress 

Diverse layers of 
trauma that, for 
most, started in 
childhood, and 
were later 
exacerbated by 
interpersonal 
trauma in 
adulthood  

The couple 
relationship itself 
served as an emotional 
space that both 
continually activated 
partners’ relational 
distress but also 
conversely facilitated 
partners’ awareness 
and ability to 
recognize the presence 
of ongoing traumatic 
stress symptoms as 
they played out within 
the intimate 
relationship 

Partners’ ability to 
gain a genuine 
understanding of their 
own and their partner’s 
trauma history and 
symptoms was a key 
ingredient to managing 
disturbances in their 
relationship 

The role of hope 
and importance 
shifting from 
individual to 
relational coping: 
Developing a 
healing team.  

Despite the 
complex trauma 
histories of this 
sample, couples 
displayed hope for 
their relationships 
and pride for the 
work they had done 
in the face of their 
difficulties and 
struggles as 
survivors of 
CPTSD, at times 
jointly managing 
severe ongoing 
symptomology 

229 

 
 
 
 
APPENDIX I: STUDY TWO—FRAMEWORK MATRIX 

Category  
Reasons for seeking EFT  

Theme 
A Relational crisis and 
the need to learn how 
to be together 

Participant expectations of 
EFT  

A Changed perspective: 
from solving to 
bonding   

Participant Experiences of 
core EFT interventions. 

Cycle tracking: A new 
perspective on couple 
conflict via the 
attachment reframe  

Summary 
Participants described ongoing 
relational distress related to past 
trauma and CPTSD, and a tipping 
point within their relationship 
and/or a triggering event that 
served as the catalyst for their 
participation in couple therapy 

Participant couples noted a 
difference between what they 
expected from treatment and what 
they experienced from EFT (so far). 
More specifically, couples described 
entering couple therapy with the 
agenda of “fixing” their relational 
issues and found it was more about 
accessing their emotions  

Reframing couples’ conflict through 
the lens of adult attachment; that is, 
conflict between partners was 
framed as rooted in the unmet 
attachment needs of emotional 
safety, security, and accessibility 
between partners was a paradigm 
shift of how they experienced the 
relationship   

230 

 
 
 
 
 
 
 
Emotional conjecture 
helped partners name 
their emotions and 
express vulnerability 

Due to the heightened and chronic 
experiences of emotional 
constriction, hypervigilance, 
reexperiencing, and avoidance 
within this sample CPTSD 
population, the utility of emotional 
conjecture was essential and helped 
partners name their emotions and 
get out of cycles of fearful reactivity  

Process over content: 
redirection to what is 
important  

Participants relayed that an 
essential component of the EFT 
intervention was when therapists to 
redirected them to their present 
process rather than the content of 
their arguments  

Successful enactments 
lead to important 
relational shifts for 
trauma survivor 
couples 

Participants relayed enactments 
were difficult, surprising, jarring, 
and awkward, but led to deeper 
sustainable shifts outside of therapy 
in the way they related to each 
other  

Participant Experiences of 
the EFT Pursuer and 
Withdrawer Framework.  

Withdrawer 
reengagement: shifting 
out of protection mode 

Getting past blame: ‘all 
I saw was my pain’. 

Process of becoming receptive to 
emotional experiencing despite 
fear-based CPTSD symptoms 
surrounding experiencing emotions 
in the context of relationship  

Though partners did not specifically 
discuss the blamer softening event, 
participants discussed how EFT 
helped them restructure their 
former patterns of blame within the 
relationship  

231 

 
 
 
 
 
 
 
 
 
 
 
 
General Couple Therapist 
factors 

Balanced Alliance: 
Helping ‘us’.  

Participants expressed the 
importance of how their therapist’s 
positive regard and attunement was 
felt mutually between partners 

Genuine emotional 
safety from therapists 
facilitated the 
therapeutic 
environment.  

Emotional safety was a key 
therapist factor that allowed clients 
to not only stay committed to 
therapy but also helped them make 
therapeutic gains within their 
relationship 

Participants perception of 
the fit and acceptability of 
EFT in the context of CPTSD  

EFT was a good fit and 
a positive experience 
for CPTSD couples 

All participants described a positive 
experience of EFT with their current 
therapists and relayed how EFT fit 
well with their relational needs as a 
couple in the context of CPTSD.  

Partners, especially those further 
along in the EFT detailed a shift in 
their bond and emotional 
connection and general way of 
relating to each other amidst and 
outside of distress 

Importance of therapist 
competency in trauma-informed 
care: therapists trained and allied 
with the population  

Participants described a stark 
difference between EFT with their 
current therapists and prior 
experiences of others forms of 
couple treatment with non-EFT 
therapists 

EFT facilitated a new 
way of relating: Co-
creating safety in the 
context of trauma 
symptomology.  

 Trauma therapy 
competency is key.  

Participants preferred 
EFT in comparison to 
prior relational 
therapies. 

232 

 
 
 
 
 
 
 
 
 
The importance of a 
collaborative process. 

Visibility and 
accessibility of EFT for 
CPTSD populations  

Participants desired an 
understanding of the goals of EFT 
while also a lack of constraints in 
terms of a prescribed timeline  

Indirect barriers to EFT related to a 
lack of awareness about the model 
and access to therapy and EFT 
therapists by location  

Cohesive care and the 
meaningful integration 
with individual 
therapy.  

Benefits and drawbacks to meeting 
with individual therapists during the 
course of treatment  

233