Exploring patterns of relationship between family ... · +Overview Background to the study...
Transcript of Exploring patterns of relationship between family ... · +Overview Background to the study...
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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
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