+

Exploring patterns of relationship

between family constellation factors and

trauma symptomatisation.

Emma Gatfield & Raymond Ho

+Overview

Background to the study – literature: trauma, family

constellation, systemic understandings of

constellation and trauma

Aims of study and research questions 1 & 2

CYMHS Research context

Method (including a diversionary discussion)

Investigation of existing trauma work in family

therapy

Limitations of study

+Background context:

Trauma

Trauma has been described in a range of ways: Simple and complex trauma or type 1 and type 2

Simple or type 1 trauma results from a single traumatic event

Complex or type 2 trauma results from repeated trauma events or severe and protracted trauma experiences (James & MacKinnon, 2012; McDermott, 2004)

Trauma impacts the brain development of children (Cook et.al., 2005; Spates, Samarweera, Plaisier, Souza & Otusi, 2007)

Heavy trauma generates defensive operations i.e. aggression, denial, sleep disturbance, self-anaesthesiaand dissociation (Briere & Lanktree, 2012; Spates et al., 2007; Stein & Kendall, 2004)

+ Background context: Trauma

Trauma responses can be grouped as: hyperarousal,

avoidance and numbing, and re-experiencing (Blake,

Weathers, Nagy, Kaloupek, Gusman, Charney & Keane, 1995; Bryant,

Moulds & Guthrie, 2000; Tarren-Sweeney, 2013)

Trauma diagnoses may include: depression, generalised

anxiety, panic attacks, borderline personality disorder

(paediatric BPD), eating disorder, ADHD, ADD etc. (Lejonclou,

Nilsson & Holmkvist, 2014; Watson, Gallagher, Dougall, Porter, Moncrieff,

Ferrier & Young, 2014)

Ethnocultural-specific symptoms i.e. visions, nervous attack, spirit

possession (Cook et al., 2005)

Family therapy conceptualisations are non-pathologising:

“trauma symptoms are a unique set of interactive coping

symptomisations that may have long term developmental

impact” (MacKinnon, 2012)

+ Background context: Trauma and

child development

Trauma during infancy and childhood significantly impacts development and function by interrupting developmental continuity… Shapes the architecture of the brain (Arsenault, Cannon,

Fisher, Polancyzk, Moffit & Caspi, 2011; Powell, Cooper, Hoffman & Marvin, 2014)

Traumatic stress precipitates a chemical imbalance causing:dysfunctions of learning, memory, behaviour and emotions, and negative personality effects. (Spates et al., 2007)

Systemic approaches position family as central in addressing trauma:

– often whole family is impacted by trauma/vicarious trauma

– attachment relationships crucial to addressing some traumas

(Foote, 1999; Hanney & Kozlowska, 2002)

+ Background context:

Family Constellation

Family structure plays an important role in level of family

function (Ahrons, 2006; Amato, 2010; Kelly, 2007)

Link between parental separation (and quality of co-

parenting relationship) and :

adjustment difficulties,

Mental and physical health concerns,

Low scores on emotional, behavioural, social and academic

outcomes (Ahrons, 2006; Amato, 2010; Kelly, 2007; Irving, Benjamin & Troche,

1984)

Family constellation disruption:

May be traumatising for children,

May disrupt important family lifecycle stages,

Often involves loss of broader supportive family systems

+Background context: Family

therapy - constellation and trauma

Limited Literature in this area

Would different family constellation affect the

family’s and the children’s recovery from trauma?

If family constellation change are somewhat link to

children’s trauma experience, would such

information improve the family therapist’s

accuracy to choose the right treatment target?

+Focus of study and research aims

Gap in the literature this study will investigate: Many factors are not well understood regarding the impact of family constellation-related factors and young people’s experiences of trauma.

To identify whether intact family constellations coincide with lower levels of trauma symptomisationfor children than do family constellations that are mobile, changing or fluid; and

To determine implications from a file audit examination for family therapy practice that addresses trauma.

+Research questions.

1. Do intact families, where biological parents

and their biological, under 16 year old

children live together, exhibit different levels

of trauma symptoms to children and youth

from families that are non-intact?

2. What implications can be drawn from

findings of the first research question for the

best practice of family therapy that addresses

trauma?

+Setting up research in the CYMHS

context.

Research & Ethic approval processes

Team level

ACU level

Service Division

Health Service

Statewide level

Seek assistance from the research support unit as early as

possible

Study the application protocol

Be patient & endure

+Research question 1:

Method

Mixed method file audit investigation and analysis (CYMHS database, Consumer Integrated Mental Health Application [CIMHA])

Phenomena of interest: client age and gender; family constellation; number of children at home/not at home; family mental illness; age of child at time of parental separation; number of constellation changes over time; number of therapy sessions; CGAS rating; ICD10 diagnoses; number of trauma symptoms

File audit sampling procedures for CYMHS data incorporating Logan City and Bayside regions

Exclusion criteria: clients with no experiences of trauma; clients with a disability; clients living in out of home care (kinship care included)

+Research question 1:

Method (continued)

Sample: n=64

CYMHS clients who had been exposed to potentially

traumatising experiences

Intact n=32 Non-intact n=32

Female n=16 Male n=16 Female n=16 Male n=16

Early Childhood

(3-5 years) n=4

Middle Childhood

(6-11 years) n=4

Pubescence (12-14 years) n=4

Adolescence (15-18 years) n=4

Early Childhood

(3-5 years) n=4

Middle Childhood

(6-11 years) n=4

Pubescence (12-14 years) n=4

Adolescence (15-18 years) n=4

Early Childhood

(3-5 years) n=4

Middle Childhood

(6-11 years) n=4

Pubescence (12-14 years) n=4

Adolescence (15-18 years) n=4

Early Childhood

(3-5 years) n=4

Middle Childhood

(6-11 years) n=4

Pubescence (12-14 years) n=4

Adolescence (15-18 years) n=4

+ Research question 1:Exploratory trauma symptom measure

Categories were derived from empirical

measures:

Acute Stress Disorder Scale (Bryant, Moulds & Guthrie, 2000)

Clinician-Administered PTSD Scale for DSM IV (Blake et al.,

1995)

Assessment Checklist for Children (Tarren-Sweeney, 2013)

Assessment Checklist for Adolescents (Tarren-Sweeney,

2013)

+Research question 1:Exploratory trauma symptom measure

Three symptom categories/17 items

Re-experiencing symptoms (3 items):

dreams, nightmares and/or hallucinations;

physiological or psychological distress at exposure to cues;

intrusive memories and flashbacks

Avoidance and numbing (5 items):

avoidance of specific activities and/or diminished interest in activities;

detachment, estrangement, dissociation, numbness, dazed, unable to

recall aspects of trauma;

future hopelessness/sense of foreshortened future, suicidal thoughts

and behaviours;

restricted affect, withdrawn, affectionless, non-communicative

+ Exploratory trauma symptom

measure(continued)

Hyperarousal, emotional and behavioural

dysregulation (9 items):

difficulty falling or staying asleep;

irritability, outbursts of anger;

impusivity, and/or major behavioural/emotional changes from premorbid

state;

hypervigilance, wariness or hyperalertness (including separation anxiety);

automatic physiological responsiveness (sweating, trembling, difficulty

breathing, racing heart) and or physiological complaints (headache,

stomachache, nausea, panic attacks);

difficulty concentrating;

violent, aggressive;

secretive, suspicious, mistrusting;

maladaptive self-soothing behaviours including sexualised and eating

disordered behaviour and hyperchondriacal symptoms

+A brief diversionary discussion:

Trauma events v. trauma experiences

Trauma is generally defined by the experience it

induces in the individual… the “traumatised” or the

“survivors of trauma”

Physiologically: stress and distress lead to a universal

set of personally nuanced physiological responses

involving the:

Autonomic nervous system, and

Limbic system (Codrington, 2010).

Yet trauma definitions refer more clearly to trauma as a

response to a traumatic event or events

+ DSMV & ICD10 trauma definitions

ICD10 diagnosis for Post Traumatic Stress Disorder (PTSD)

“Criterion A : The person has been exposed to a traumatic event…

Criterion B: The traumatic event is persistently reexperienced…“

ICD10 diagnosis for Adjustment Disorder (AD)

“The disorder is caused by psychosocial stress of a not unusual extent. Symptoms occur within one month.” (presumably of the psychosocial stress event(s))

DSMV diagnosis for PTSD: the first criterion has 4 components:

Directly experiencing the traumatic event(s)

Witnessing, in person, the event(s) as it occurred to others

Learning that the traumatic event(s) occurred to a close family member or friend

Experiencing repeated or extreme exposure to aversive details of the traumatic event(s)”

Acute Stress Reaction and AD are described in DSMV as responses to stressful life event(s)

+A brief diversionary discussion:

Trauma events v. trauma

experiences

There is a needed definitional shift of focus from EVENTS as

causing trauma to an emphasis on an individual’s

EXPERIENCE, that we may define as traumatised, as reflected

in our psychological trauma measures.

Systemic perspective: individuals’ and families narratives

and internal processes influence:

impact of trauma,

resilience to trauma, and

symptomising responses to trauma.

+Research question 1: Method –

Data Analysis

Intact and non-intact family cohort data will be analysed using SPSS 22 (2012) for identifiable patterns, using nonparametric testing:

Chi square

Fisher’s exact test

Crosstabulation

Frequency exploration.

Phenomena of interest, compared for both intact or non-intact family status AND number of trauma symptoms:

Number of children living in clients’ family home/s and number of children not living in client’s family home/s

Family members with a mental illness: immediate family or extended family or a combination of both

Age of client at time of first family separation

Number of therapeutic sessions attended

+Research question 2

Method: Literature survey

Implications from findings of file audit

investigation, set against contemporary family

therapy literature for trauma presentations

Of interest:

therapeutic practice that supports low levels of

trauma symptoms, and

therapeutic practice that affirms supportive family

structures.

+Research question 2: Implications

for practice - trauma work in family

therapy

Central systemic approaches to trauma therapy:

1. Attachment theory-based approaches

2. Narrative/dialogical approaches

3. Other interventions i.e. Bowen and social constructionist approaches

Most approaches have a skills training or physiological regulation component to support symptom management i.e. components of DBT, mindfulness, grounding, anchoring, Radical Exposure Tapping, Emotional Freedom Technique and Eye Movement Desensitisation & Reprocessing (Greenland, 2010; Greenwald, 2005; Linehan, 1993; Rothschild, 2010;

MacKinnon, 2014)

+Implications for practice:

Trauma work in family therapy –Attachment theory-based approaches

Attachment theory-based approaches:

View child’s primary attachment system as crucial to trauma

healing

Utilise strength of primary attachment relationships to promote

safety, symptom management and trauma resolution

i.e. creating illustrated storybooks in family therapy (Hanney

& Kozlowska, 2002); Theraplay (Jernberg & Booth, 2001);

Family Attachment Narrative Therapy (FANT) (Lacher,

Nichols & May, 2005); Dyadic Developmental Therapy (DDP)

(Hughes, 2005); and Attachment Based Family Therapy

(ABFT) (Diamond et al., 2014).

+Implications for trauma work in

family therapy: Narrative/dialogical

approaches

Narrative and dialogical approaches focus on:

the development of alternative or secondary or

subordinate storylines to the dominant trauma narrative, or

the generation of a dialogically processed trauma picture,

often involving genograms, trauma timelines and lists.

i.e. Subordinate or secondary storylines (Yuen, 2007;

White, 2005); Story writing with the chronically ill (Penn,

2001); Interventions utilising genograms and trauma

timelines (Figley & Kisler, 2013; James & MacKinnon, 2012;

Jordan, 2006)

+Implications for trauma work in

family therapy: Other interventions

Several efficacious approaches incorporate

meaning-making process and system-value

processing, informed by:

Bowen ideas

social constructionist ideas

i.e. Multidimensional Family Therapy (Liddle,

2013); Ceremony-based approaches to group

trauma therapy (Lubin & Johnson, 2015)

+ Implications for trauma work in

family therapy: Family mental illness

and resilience

For family therapy work with traumatised children, families

often have a complex of mental illness across family

members that need to be addressed when working

systemically

Promoting families’ resilience is important for helping

families:

recognise strengths they have developed in their life struggles,

become empowered to recover, and

learn from adversity and integrate experiences (Schaaf, 2012; Ungar, 2013;

Walsh 2003; Walsh, 1996).

+ Limitations of study

Research question may have potential errors

in findings:

client case managers and other involved clinicians

under-reporting, over-reporting or inaccurately

reporting

researcher error in translating phenomena

documented in cases into codable data

variabilities of reporting in files.

While variability or inaccuracy in file data may

be unavoidable researcher error in translating

phenomena into coded data this will be reduced

through the process of expert panel validation.

+Limitations of study

(continued)

Other limitations include issues of generalisability of study findings to standard Australian populations, since:

all clients to be investigated have a trauma history and have experienced mental health problems significant enough to warrant support from CYMHS,

this study uses a small sample size

a limited demographic is represented by the cohort

a nuanced ethnic, racial, cultural, religious and SES grouping is represented by the study population

+Limitations of study

(continued)

Due to the categorical nature of data,

nonparametric test analysis will be undertaken.

A larger sample and continuous data would

enable parametric testing which may yield more

statistically powerful results

Limitations relating to research question two

involve the likely outcome that it will provide an

incomplete survey of family therapy trauma

research

+ References

Ahrons, C.R. (2006). Family ties after divorce: Long-term implications for children. Family Process, 46(1), 53-64.

Amato, P.R. (2010). Research on divorce: Continuing trends and new development. Journal of Marriage and Family, 72, 650-666.

Arsenault, L., Cannon, M., Fisher, H.L., Polanczyk, G., Moffitt, T.E., & Caspi, A. (2011). Childhood trauma and children's emerging psychotic symptoms: A genetically sensitive longitudinal cohort study, The American Journal of Psychiatry, 1, 65-72.

Blake, D.D., Weathers, F.W., Nagy, L.M., Kaloupek, D.G., Gusman, F.D., Charney, D.S., & Keane, T.M. (1995). The development of a clinician-administered PTSD scale. Journal of Traumatic Stress, 8(1). 75-90.

Briere, J.N., & Lanktree, C.B. (2012). Treating complex trauma in adolescents and young adults. Thousand Oaks, CA: Sage Publications.

Bruun, A., & Mitchell, P. (2012). A resource for strengthening therapeutic practice frameworks in youth alcohol and other drug services. Melbourne: Youth Substance and Alcohol Services Pty Ltd.

Bryant, R.A., Moulds, M.L., & Guthrie, R.M. (2000). Acute stress disorder scale: A self-report measure of acute stress disorder. Psychological Assessment, 12(1), 61-68.

+Codrington, R. (2010). A family therapist’s look into interpersonal neurobiology and the adolescent brain: An interview with Daniel Siegel. The Australian and New Zealand Journal of Family Therapy, 31(3), 285-299.

Cook, A., Spinazzola, J., Ford, J., Lanktree, C., Blaustein, M., Cloitre, M., DeRosa, R., Hubbard, R., Kagan, R., Liautaud, J., Mallah, K., Olafson, E., & Van der Kolk, B. (2005). Complex trauma in children and adolescents. Psychiatric Annals, 35(5), 390-398.

Diamond, G., Levy, S., & Diamond, G. (2014). Attachment based family therapy: An introductory workshop, Philadelphia, PA: author.

Figley, C., & Kister, L. (2013). Helping traumatised families (2nd ed.), New York, NY: Routledge.

Foote, W. (1999). Unravelling the web of deceit: Enduring perpetrator dynamics and recovery from child sexual assault. The Australian and New Zealand Journal of Family Therapy, 20(2), 70-77.

Greenland, S.K. (2010) The mindful child, New York, NY: Free Press.

Greenwald, R. (2005). Child trauma handbook: A guide for helping trauma-exposed children and adolescents, New York, NY: Haworth Maltreatment and Trauma Press.

Hanney, L., & Kozlowska, K. (2002). Healing traumatised children: Creating illustrated storybooks in family therapy. Family Process, 41(1), 37-64.

+ Hughes, D.A. (2005). An attachment-focussed treatment for foster and adoptive families. British Psychological Society Service and Practice Update, 4(4), 26-28.

Irving, H.H., Benjamin, M., & Troche, N. (1984). Shared parenting: An empirical analysis utilising a large data base. Family Process, 23, 561-569.

James, K., & MacKinnon, L. (2012). Integrating a trauma lens into a family therapy framework: Ten principles for family therapists, The Australian and New Zealand Journal of Family Therapy, 33(3), 189-209.

Jernberg, A.M., & Booth, P.B. (2001). Theraplay: Helping parents and children build better relationships through attachment-based play. San Francisco, LA: Jossey Bass.

Jordan, K. (2005). The scripto-trauma genogram: An innovation technique for working with trauma survivors’ intrusive memories. Brief Treatment and Crisis Intervention, 6(1), 36-52.

Kelly, J.B. (2006). Children's living arrangements following separation and divorce: Insights from empirical and clinical research. Family Process, 46(1), 35-52.

Lacher, D., Nichols, T., & May, J. (2005). Connecting with kids through stories: Using narratives to facilitate attachment in adopted children, London: Jessica Kingsley.

Lejonclou, A., Nilsson, D., & Holmqvist, R. (2014). Variants of potentially traumatising life events in eating disorder patients. Psychological Trauma: Theory, Research, Practice and Policy, 6(6), 661-667.

+ Liddle, H.A. (2013). Multidimensional family therapy for adolescent substance

abuse: A developmental approach. In P.M. Miller (Ed.), Interventions

for addiction: Comprehensive addictive behaviours and disorders (5th ed.),

(pp. 87-96). San Diego, CA: Elsevier Science Publishing Co.

Linehan, M.M. (1993). Skills training manual for treating borderline personality

disorder, New York, NY: The Guildford Press.

Lubin, H. & Johnson, D.R. (2015). Use of ceremony in multiple family therapy for

psychological trauma. In H. Lubin & D.R. Johnson (Eds.), Principles

and techniques of trauma-centred psychotherapy, (pp. 75-100).

Arlington, VA: American Psychiatric Publishing.

MacKinnon, L. (2014). Deactivating the buttons: Integrating radical exposure

tapping with a family therapy framework. The Australian and New

Zealand Journal of Family Therapy, 35, 244-260.

McDermott, B. (2011). Child and youth emotional trauma: An explanatory model of

adverse outcomes. Psychiatry, Psychology and Law, 11(2), 269-279.

Penn, P. (2001). Chronic illness: Trauma, language, and writing: Breaking the

silence. Family Process, 40(1), 33-52.

Rothschild, B. (2010). Eight keys safe trauma recovery: Take charge strategies to

empower your healing, New York, NY: Norton & Co.

+Schaaf, A.K. (2012). Journey through trauma. The Journal of Applied Christian Leadership, 6(2), 34-56.

Spates, R.C., Samaraweera, N., Plaisier, B., Souza, T., & Otsui, K. (2007). Psychological impact of trauma on developing children and youth. Primary Care: Clinics in Office Practice, 34, 387-405.

Stein, P.T. & Kendall, J.C. (2004). Psychological trauma and the developing brain: Neurologically based interventions for troubled children, New York, NY: Haworth Maltreatment and Trauma Press.

Tarren-Sweeney, M. (2013). Clinician's guide to assessment checklist series: Specialised mental health measures for children in care, Taylor & Francis.

Ungar, M. (2013). Resilience, trauma, context and culture. Trauma, Violence and Abuse, 14(3), 255-266.

Velez, C.E., Wolchik, S.A., Tein, J., & Sandler, I. (2011). Protecting children from the consequences of divorce: A longitudinal study of the effects of parenting on children's coping processes. Child Development, 82(1), 244-257.

Walsh, F. (1996). Special section: Family resilience: A concept and its application: The concept of family resilience: Crisis and challenge. Family Process, 35, 261-281.

Walsh, F. (2003). Family resilience: A framework for clinical practice. Family Process, 42(1), 1-18.

+ Watson, S., Gallagher, P., Dougall, D., Porter, R., Moncrieff, J., Ferrier, I.N., &

Young, A.H. (2014). Childhood trauma in bipolar disorder. The

Australian and New Zealand Journal of Family Therapy, 48(6), 564-570.

Yuen, A. (2007). Discovering children's responses to trauma: a response-based

narrative practice. The International Journal of Narrative Therapy and

Community Work, 4, 3-18.