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The Family that Works Together Stays Together:

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Suzanne Millman

on 19 March 2014

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Transcript of The Family that Works Together Stays Together:



Improve family cohesion




A Family that Works Together Stays Together:
A family systems approach to trauma focused
assessment and treatment

Learning Objectives

Explore effective family trauma assessment strategies

Understand how to engage families who have experienced complex trauma

Learn how to implement effective evidence based treatment approaches for families who have experienced trauma

Why is Family Therapy for
Trauma Important?
12 Core Concepts for Understanding Traumatic Stress Responses in Childhood
1. traumatic experiences are inherently complex
2. trauma occurs within a broad context that includes children's personal characteristics, life experiences, and current circumstances.
3. traumatic events often generate secondary adversities, life changes, and distressing reminders in children's daily lives.
4. children can exhibit a wide range of reactions to trauma and loss.
5. danger and safety are core concerns in the lives of traumatized children.
6. Traumatic experiences affect the family and broader caregiver systems.
7. Protective and promotive factors can reduce the adverse impact of trauma
8. trauma and post trauma adversities can strongly influence development
9. Developmental neurobiology underlies children's reactions to traumatic experiences
10. culture is closely interwoven with traumatic experiences, response and recovery
11. challenges to social contract, including legal and ethical issues, affect trauma response and recovery
12. working with trauma- exposed children can evoke distress in providers that make it more difficult for them to provide good care
Engagement Strategies
strengths based
culturally sensitive
who should be in room: parents, siblings, all affected?
validate why or why not present
acknowledge
join
establish physical comfort
share control about process
establish caregiver has volition

Assessment of Family Trauma
Measuring tools
PTSD ADIS questionnaire
UCLA PTSD scale
Parenting Stress Index short form
Family Assessment Form (FAF)
Adverse Childhood Experiences Scale (ACES)

Used to help the diagnostic process after a traumatic event
Testing can range from 5-20 minutes
Scoring can take about 5- 10 minutes
immediate basic needs

environmental stressors

immediate risks and protections

level of family cohesion and conflict

readiness to set the stage/prepare for change
5 Guiding Principles for Trauma-Focused Family Treatment
Most existing evidence based trauma focused treatments
primarily address the person
or persons
directly impacted by trauma.
These treatments
neglect the system
within which the traumatized individual lives ( Figley & Figley, 2009)

The
impact of trauma extends beyond individual
who was directly involved in the event. When something bad happens
family, friends, neighbors, communities, and even larger society may be affected
(Sinani Centre, 2003)

Trauma can affect
couples
(Whiffen & Oliver, 2004), the
parent–child interaction
(Steinberg, Brymer, Decker, & Pynoos, 2004), and
intergenerational dynamics
(Daud, Skoglund, & Rydelius, 2005)


Make implicit dynamics explicit

Be aware of avoidance - common reaction to trauma, and potentially more common in family settings

Assess for and address negative cognitions at the core of traumatic memories

Explore each individual family member's experience of the trauma - collaborative narratives

Monitor for vicarious traumatization

Types of Trauma
sexual abuse
physical abuse
emotional abuse
neglect
medical events
family violence
domestic violence
traumatic loss/separation
community violence
natural/man made disaster
political violence
cultural violence
Treatment Goals
"the aim of family approaches to trauma is to reactivate the healing process within the family" (Coulter 2011).

create strengthening stories
enhance interpersonal relationships
increase positive communication
enrich functioning of family unit
help family make sense of events by creating a shared family meaning of traumatic context
challenge distorted perceptions and increase family well-being
engage families in narrative conversations beginning within the assessment and psychoeducation intervention sessions
Impact of Trauma on Children
Trauma can negatively affect children in the following ways:

Increase affect, emotional, and behavioral dysregulation

increase aggression, irritability, & difficulty concentrating

increase risk for other psychiatric disorders including depression & anxiety

decrease school/academic functioning

decrease social functioning
Prevalence of Trauma
Percentage of
youth exposed to trauma ranges from 8% to 53%
, (Copeland, et. al, 2007; Finkelhor, et. al. 2005; U.S. DHHS 2011).

More than 68%
of children and adolescents had experienced a potentially traumatic event by the
age of 16
(Copeland, W.E., Keeler, G., Angold, A., Costello, E.J. 2007).

Inner city
community: 30% witnessed a
stabbing
& 26% witnessed a
shooting
(Bell & Jenkins 1993)

Treatment Components
Family trauma narrative or family timeline
co-constructed
multiple viewpoints are considered & integrated into shared vision of story
build narrative skills
each member contributes to story
give & take
reflectivity

Treatment Outcomes
Healing of Family Narrative
Improved communication processes

Ability to talk about difficult issues

Relationships repaired

Increasing tolerance for negative affect

Collaborative problem solving

Barriers to Treatment &
Challenges within Treatment
unmet basic needs
safety, shelter, transportation

managing complexity
attending to each individuals' response to trauma
missing family members within treatment sessions

References
Barnes, M.F. (2005). When a child is traumatized or physically injured: The secondary trauma of parents. In D.R. Catherall (Ed.), Specific Stressors: Interventions with couples and families (pp. 73—90). New York: Brunner-Routledge.

Bell, C.C. & Jenkins E.J. (1993) Community violence and children on Chicago's Southside, Psychiatry, 56 (1): 46-54.

Cook, A., Spinazzola, J., Ford, J., Lanktree, C., Blaustein, M., Cloitre, M., et al. (2005). Complex trauma in children and adolescents. Psychiatric Annals, 35, 390-398.

Connors, K. MSW, Gardner, S. MSW Kaiser, L. Ph.D., MBA & Strider, F. Ph.D., MSW (March 5, 2012). Family Informed Trauma Treatments: Lessons learned in supporting family recovery. NTCSN All Network Conference, Lectured from Baltimore, MD.

Cohen, J.A., Mannrino, A.P., Murray, L.K., & Igelman R. (2006). Psychosocial interventions for maltreated and violence-exposed children
. Journal of Social Issues
, 63(4), p. 737-766

Copeland, W.E., Keeler, G., Angold, A., Costello, E.J. (2007). Traumatic events and posttraumatic stress in childhood. Archives of General Psychiatry, 64 (5): 577-584.

Coulter, S. (2014). The Applicability of Two Strengths-based Systemic Psychotherapy Models for Young People Following Type 1 Trauma. Child Care In Practice, 20(1), 48-63.

Daud, A., Skoglund, E., & Rydelius, P. (2005). Children in families of torture victims: Transgenerational transmission of parents’ traumatic experiences to their children. International Journal of Social Welfare, 14, 23–32.

Figley, C. R., & Figley, K. (2009). Stemming the Tide of Trauma Systemically: The Role of Family Therapy. Australian & New Zealand Journal Of Family Therapy, 30(3), 173-183.

Giaconia, R., Reinherz, H., Silverman, A., Bilge, P., Frost, A. & Cohen, E. (1995) Traumas and posttraumatic stress disorder in a community population of older adolescents. Journal of the American Academy of Child and Adolescent Psychiatry. 34: 1369-1380.

James, K., & MacKinnon, L. (2012). Integrating a Trauma Lens into a Family Therapy Framework: Ten Principles for Family Therapists. Australian & New Zealand Journal Of Family Therapy, 33(3), 189-209.

Kilpatrick DG, Saunders BE. (1997). Prevalence and Consequences of Child Victimization: Results from the National Survey of Adolescents. National Crime Victims Research and Treatment Center, Medical University of South Carolina

Kiser, L., Connors, K., Dowling, L., Gardi, A. (March 5, 2012) Expanding your Assessment Repertoire: Introducing the family assessments of needs and strengths- trauma exposure and adaptation (FANS-TEA). NTCSN All Network Conference, Lectured from Baltimore, MD.

Layne C.M., Ippen, C.G., Strand, V., Stuber, M., Abramovitz, R., Reyes, G., Jackson L.A., Ross, L., Curtis, A., Lipscomb, L., Pynoos R. (2011). The core curriculum on childhood trauma: a tool for training a trauma-informed workforce. Psychological Trauma: Theory, Research, Practice, and Policy, 3(3), 243-252

Little, S. G., Akin-Little, A., & Somerville, M. P. (2011). Response to trauma in children: An examination of effective intervention and post-traumatic growth. School Psychology International, 32(5), 448-463. doi:10.1177/0143034311402916

Pynoos, R.S., Steinberg, A.M., & Piacentini J.C. (1999). A developmental psychopathlogy model of childhood traumatic stress and intersection with anxiety disorders. Biological Psychiatry, 46, 1542-1554.

Steinberg, A., Brymer, M., Decker, K., & Pynoos, R. (2004). The University of California at Los Angeles Posttraumatic Stress Disorder Reaction Index. Current Psychiatry Reports, 6, 96–100.

Whiffen, V. E., & Oliver, L. E. (2004). The relationship between traumatic stress and marital intimacy. In D. R. Catherall (Ed.), Handbook of stress, trauma, and the family (pp. 139–159). New York, NY: Brunner–Routledge.
Active Ingredient in
Trauma Treatment
Systematic Meaning Making

Family members' perceptions of the amount of stress caused by a traumatic event often impacts development of coping skills and emotional sequelae more than the observable consequences of the trauma.

This indicates the need for therapists to examine each family members' interpretation of the traumatic event and integrate these into a collaborative trauma narrative.
Stabilization
Introduction
Assessment

Attend to Safety

Use a "roadmap" - trauma focused genograms

Screen each member of the family for trauma related symptoms (i.e. standardized tools for PTSD, anxiety, and depression)

Traumatic events are located within a network of relationships

Exploring problematic relationship dynamics can serve as a window to implicit memories of trauma and possible triggers

5 Guiding Principles for Trauma-Focused Family Assessment
Treatment
Case Example
Compiled from 10 guiding principles for TF family assessment treatment
Researchers completed a search of family therapy literature to date concerning trauma ( James & MacKinnon, 2012)
Exposure to multiple traumas can lead to
increases affective and physiological dysregulations, attachment disturbances, alterations in con¬sciousness and self-perception, and changes in systems of personal meaning

Without adequate and appropriate treatment,
trauma symptoms may linger or exacerbate over time,
developing into other mental health problems such as
internalizing or externalizing disorders


Lack of treatment may increase secondary adversities including
health problems, home and foster home placement disruptions, school difficulties, social maladjustment, and substance abuse

Impact of Trauma on Children
Kiser, L., Connors, K., Dowling, L., Gardi, A. (March 5, 2012) Expanding your Assessment Repertoire: Introducing the family assessments of needs and strengths- trauma exposure and adaptation (FANS-TEA). NTCSN All Network Conference, Lectured from Baltimore, MD.

Layne C.M., Ippen, C.G., Strand, V., Stuber, M., Abramovitz, R., Reyes, G., Jackson L.A., Ross, L., Curtis, A., Lipscomb, L., Pynoos R. (2011). The core curriculum on childhood trauma: a tool for training a trauma-informed workforce. Psychological Trauma: Theory, Research, Practice, and Policy, 3(3), 243-252
Pynoos, R.S., Steinberg, A.M., & Piacentini J.C. (1999). A developmental psychopathlogy model of childhood traumatic stress and intersection with anxiety disorders. Biological Psychiatry, 46, 1542-1554.


Layne C.M., Ippen, C.G., Strand, V., Stuber, M., Abramovitz, R., Reyes, G., Jackson L.A., Ross, L., Curtis, A., Lipscomb, L., Pynoos R. (2011). The core curriculum on childhood trauma: a tool for training a trauma-informed workforce. Psychological Trauma: Theory, Research, Practice, and Policy, 3(3), 243-252
Pynoos, R.S., Steinberg, A.M., & Piacentini J.C. (1999). A developmental psychopathlogy model of childhood traumatic stress and intersection with anxiety disorders. Biological Psychiatry, 46, 1542-1554.

12 Core Concepts Continued...
Collect important information
who is in the family
individual family members histories
individual family functioning/symptoms
family member roles, communication and interactions
assess individual traumatic responses
Strengthens alliance and engagement process
useful tools
Genogram, ecomap, trauma timeline

Helps to avoid retraumatization
Connors, K. MSW, Gardner, S. MSW Kaiser, L. Ph.D., MBA & Strider, F. Ph.D., MSW (March 5, 2012). Family Informed Trauma Treatments: Lessons learned in supporting family recovery. NTCSN All Network Conference, Lectured from Baltimore, MD.
Connors, K. MSW, Gardner, S. MSW Kaiser, L. Ph.D., MBA & Strider, F. Ph.D., MSW (March 5, 2012). Family Informed Trauma Treatments: Lessons learned in supporting family recovery. NTCSN All Network Conference, Lectured from Baltimore, MD.
In addition to trauma narrative, share family stories!

something good the whole family has experienced together

something a little bit scary or somewhat stressful that happened to family

discuss family future & add it to family narrative/timeline
Connors, K. MSW, Gardner, S. MSW Kaiser, L. Ph.D., MBA & Strider, F. Ph.D., MSW (March 5, 2012). Family Informed Trauma Treatments: Lessons learned in supporting family recovery. NTCSN All Network Conference, Lectured from Baltimore, MD.
Compiled from 10 guiding principles for TF family assessment treatment. Researchers completed a search of family therapy literature to date concerning trauma ( James & MacKinnon, 2012)
Connors, K. MSW, Gardner, S. MSW Kaiser, L. Ph.D., MBA & Strider, F. Ph.D., MSW (March 5, 2012). Family Informed Trauma Treatments: Lessons learned in supporting family recovery. NTCSN All Network Conference, Lectured from Baltimore, MD.
Assessment of Family Trauma Continued...
Existing Family Interventions for Trauma
From UCLA PTSD Reaction Index for DSM IV©
When something reminds me of what happened I get very upset, afraid or sad.
Circle one: None Little Some Much Most
0 1 2 3 4

I think that some part of what happened is my fault.
Circle one: None Little Some Much Most
0 1 2 3 4

I think that I will not live a long life.
Circle one: None Little Some Much Most
0 1 2 3 4

I have trouble feeling happiness or love.
Circle one: None Little Some Much Most
0 1 2 3 4

Steinberg, A. M. and Vivrette, R. (2013, February 5).
UCLA PTSD Reaction Index Administration and Scoring.
UCLA/Duke University National Center for Child Traumatic Stress. Lecture conducted from National Child Traumatic Stress Network, Los Angeles, CA.
Kiser, L., Connors, K., Dowling, L., Gardi, A. (March 5, 2012) Expanding your Assessment Repertoire: Introducing the family assessments of needs and strengths- trauma exposure and adaptation (FANS-TEA). NTCSN All Network Conference, Lectured from Baltimore, MD.
Assessment
Treatment Goals
Short Term:

Stabilization
Ensure stability of essential resources such as housing and food

Assess readiness and willingness for change


Long Term:

Improve family cohesion

Bolster family resiliency

Process grief surrounding mother's passing



Family strengths

Attend to Safety-
identify targets for stabilization

Use a "roadmap" -
trauma focused genograms
assess resulting family dynamics post-traumatic event

Screen each member of the family for trauma related symptoms (i.e. standardized tools for PTSD, anxiety, and depression)-
assess each family members' unique reaction/symptoms

Goals and Corresponding Treatment Strategies



Stabilization




Strategy
Goal
Provide referrals
individual therapy when needed
Address individual members' immediate reactions/symptoms
use info from assessment tools
Create new family routine
establish new roles and responsibilities
Goal
Treatment Strategy


Process grief surrounding mother's passing





Bolster family resiliency through development of coping skills



Goals and Corresponding Treatment Strategies Continued

collaborative trauma narrative






discussing and practicing communication and coping skills

collaborative trauma narrative


Use genogram to:
make implicit dynamics explicit
explore and define new roles in the family

Family sculpt: improve communication between family members
Multisystemic Therapy
joining/aligning family, reframing, assigning tasks to change family interaction patterns

Multifamily Group Therapy (MFGT)
family systems, group therapy, psychoeducation, CBT, and behavioral management components

Existing Family Interventions for Trauma
Trauma Focused- Cognitive Behavioral Therapy (TF-CBT)

components: parenting skills, psychoeducation, relaxation skills, affective modulation skills, cognitive processing, trauma narration, in vivo desensitization, conjoining- parent sessions & enhancing safety & future development


Further adaptations included actively involving parents in behavioral management skills, parent child communication skills, parents encouraged to monitor own emotional reactions to provide appropriate modeling of coping for their children, & including caregivers in creation of trauma narrative
Challenges in Treatment
New Crises

Managing varied individual reactions in session

Only some family members participate in sessions.

Self care
Cohen, J.A., Mannrino, A.P., Murray, L.K., & Igelman R. (2006). Psychosocial interventions for maltreated and violence-exposed children
. Journal of Social Issues
, 63(4), p. 737-766
Cohen, J.A., Mannrino, A.P., Murray, L.K., & Igelman R. (2006). Psychosocial interventions for maltreated and violence-exposed children. Journal of Social Issues, 63(4), p. 737-766
Kiser, L., Connors, K., Dowling, L., Gardi, A. (March 5, 2012) Expanding your Assessment Repertoire: Introducing the family assessments of needs and strengths- trauma exposure and adaptation (FANS-TEA). NTCSN All Network Conference, Lectured from Baltimore, MD.
example genogram
UCLA PTSD Sample Questions
Figley, C. R., & Figley, K. (2009). Stemming the Tide of Trauma Systemically: The Role of Family Therapy. Australian & New Zealand Journal Of Family Therapy, 30(3), 173-183.
Family Genogram
Questions?
Child-Parent Psychotherapy
uses parent-child relational play, action, and language to correct specific areas that are dysregulated
creation of a joint child-parent trauma narrative of the DV that child experienced and correction of cognitive distortions related to family violence, case management

Brief Overview
Introduction: prevalence of trauma & necessity of family trauma treatment

Assessment: Engagement and assessment strategies

Treatment: evidence informed treatment components

Case Example: describe example of implementation of family trauma treatment

8% reported a lifetime prevalence of
sexual assault
, 17% reported
physical assault
, & 39% reported
witnessing violence
. (Kilpatrick & Saunders 1997).



14.5% of adolescents
who had experienced a serious trauma
developed PTSD
(Giaconia et. al. 1995).


Cook et al., 2005; Herman, 1992; Kaysen, Resick, & Wise, 2003; Kiser, Millsap, & Heston, 1992; Terr, 1991; van der Kolk, 2005
Hamblen, 1999; Hernandez, Lodico, and DiClemente, 1993; Hoven et al., 2005; Siegel and Williams, 2003
Felitti et al., 1998; Goodman, 2002; Hamblen, 1999; Myers et al., 2002; National Institute for Mental Health, 2001
Common Treatment Components
MST, MFGT, CPP, & TF-CBT
parent-child communication/interaction patterns
joining, aligning,
CBT
behavior management
individual trauma narrative

Common Components
Gaps in Treatment
May disregard other family members
siblings, grandparents, aunts or uncles

May miss other crucial points for intervention
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