Effects of trauma on implicit emotion regulation within a family system a resiliency-based approach


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This paper explores emotion regulation, family functioning, PTSD, impact of moral development and points to family therapy techniques to re-establish health in the family.

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Effects of trauma on implicit emotion regulation within a family system a resiliency-based approach

  1. 1. 3Spring/Summer 2012 Effects of Trauma on Implicit Emotion Regulation Within a Family System: A Resiliency-Based Approach FeaturedArticle Michael Changaris, PsyD T raumatic events are far from rare. An epidemiological study found that 69% of individuals in the United States are exposed to at least one traumatic event in their lifetime (Norris, 1992). According to the study, 21% experienced at least one traumatic event in the last year. Trauma can expose difculties in a family system that functions poorly, but can also negatively impact a family that functions well because traumatic events affect multiple domains of family functioning. Understanding resiliency factors can guide a clinician in developing interventions to facilitate the reduction in symptoms of trauma. A healthy family system can be a buffer against developing Post-Traumatic Stress Disorder (PTSD; McCubbin, Balling, Possin, Frierdich & Bryne, 2002). Safe supportive relationships can increase the chance that individuals will choose effective coping strategies, access appropriate health care, and will not isolate themselves from others (Betancourt & Khan, 2008). PTSD in the Family System Brief strategic family therapy practitioners (BSFT) assess families across multiple domains of functioning, including conict resolution, family organization, and resonance (Szapocznik, Hervis & Schwartz, 2003). Symptoms of PTSD within one individual or multiple members of a family dramatically impact these domains. Conict resolution skills are reduced by changes in Hypothalamic Pituitary Adrenal –– Axis (HPA-Axis) reactivity. Increased startle response can escalate family arguments quickly. Avoidance-based coping can lead to unresolved conicts and intense silences burdened with unmet emotional needs. Family organization can be dramatically altered by traumatic events either directly or through profound changes in individuals’’ functioning (Ochberg, 1988). For instance, a father who has been supportive and nurturing might become brooding and quick-tempered after witnessing a death on the job. Resonance describes patterns of distance and closeness in a family system. Symptoms of PTSD can alter families’’ ability to maintain and develop exible boundaries. After a traumatic event, some families develop rigid boundaries, while others become highly enmeshed (Ochberg, 1988). Avoidance and numbing can create distance, making it difcult to feel connected. As one individual in therapy with the author reported, ““my heart does not feel anything when I see my (family member).”” In a family system, symptoms of PTSD, may lead to multiple alterations in how the family relates to the identied patient (IP). The individual labeled as the IP is often not the person directly exposed to the trauma. For example, a teenager may feel isolated and act-out in inappropriate ways when failing to connect with a parent who is grieving the recent loss of a loved one to cancer. At times, the individual who has symptoms of trauma has an intense shame reaction to being viewed as the IP, leading to a rigid pattern of acting out. The developmental stage of a family can be altered by a traumatic event (Ochberg, 1988). Symptoms of trauma can lead family members to isolate themselves from others or be highly irritable at a time when their family needs support to manage the transition to a new stage of family development, such as the birth of a child. Development of Emotion Regulation and Morality in Family Systems The family is the training ground for learning emotional regulation and basic morality. Children learn to tolerate a wide range of emotional experiences through the rupture-and-repair cycle in family interactions. A child who becomes angry with her parents, but tolerates the emotions involved in resolving the conict, strengthens her ability to handle anger and develops mastery experiences of affect regulation. The ability to regulate emotions is a complex interaction between genetic, epic-genetic, and experiential factors. It is important to understand that emotional regulation is not a unitary construct, but comprises a range of skills and abilities. Some of the core domains of emotional regulation are auto-regulation (the innate ability to regulate emotions), cognitive regulation (the use of a conscious skill to change emotional reaction), co-regulation (the interactional regulation of emotions through relationships), and self-regulation (the integrated working of these three domains). The ability to tolerate distress in order to maintain a relationship is a vital emotional regulation skill for the development of social and moral thinking. The consistent alternation in perspective taking between children and parents, as well as other family members, develops children’’s ability to anticipate the behavior of Michael Changaris, PsyD
  2. 2. 4 Trauma Psychology Newsletter Implicit Emotional Regulation in Family Systems Emotional regulation is vital for family functioning, and a signicant aspect of this is the cognitive appraisal of emotions. Because many arguments in families occur due to inaccurate cognitive interpretations, the family therapy interventions of decoding and reframing address this aspect of emotional regulation (Westen, 2000). The somatic marker hypothesis posits that there are two major neurological systems for processing emotions: a fast limbic circuit that appraises a situation in a global holistic manner, initially bypassing conscious awareness, and a slower emotional system that involves conscious cognitive appraisal of a situation (Bechara, Damasio, Tranel & Damasio, 2005). Porges (2007) expanded this theory describing what he called neuroception as the appraisal of threat or safety using the fast limbic circuit. Teens with PTSD were more likely than their peers without PTSD to interpret a facial expression of fear as a facial expression of anger (Rauch et al., 2000). Often the recognition of an emotion is non-deliberative and does not involve conscious processes (Zajonc, 1984). While changing cognitive appraisal is an important aspect of treatment, the implicit emotional regulation system also has a profound impact on family functioning. It is not unusual for a body posture or a vocal tone to precipitate a family difculty. For those individuals with PTSD, triggering events for ght, ight, or freeze states can be subtle and sensory-based (van der Kolk, 2006). For instance, one individual noted in treatment with the author that slowed movements and slurred speech triggered a sense memory of being assaulted by a man who was intoxicated. Tracking the implicit interactions between family members can allow clinicians to transform a re-enactment of a family pattern to a powerful corrective experience. The non-verbal dance of communication is vital in a family system (Schore, 2001). There is a synchrony that develops in moments of attunement and leads to an experience of emotional connection and safety (Knyazev, Slobodskoj-Plusnin & Bocharov, 2009). Through supporting increased attunement, the cacophony of movements in an argument can turn into a smooth dance, as pupils dilate at the same time, breath synchronizes, and body posture once tense now mirrors another’’s. Elevated stress response and symptoms of PTSD both reduce the ability to enter into this dance, thereby reducing family resilience to stress (van der Kolk, 2006). For many individuals with PTSD, the fast limbic system often does not shift to match their children’’s emotional experiences. Verbal decoding of children’’s experience without the authenticity of an emotional response can feel as if parents are faking their response, deepening the rupture. Clinicians witnessing this type of interaction can support parents to regulate their emotional state, scaffolding the parents into emotional resonance. It is important to understand that the fast limbic system is not trained by dialog or information but by others, settle disputes, and understand cultural rules for displaying emotions. Symptoms of PTSD fundamentally alter social interactions and moral choices. Franz Dwell (as cited in Preston & de Waal, 2002) stated that the complexity of human morality rests on two major factors: empathy and reciprocity. Individuals with symptoms of PTSD have profound alterations in both areas. Fight-or-ight activation reduces the ability of individuals to have empathy for another. Symptoms of PTSD can alter patterns of reciprocity. Complex social animals support one another to reach mutual goals but expect repayment at a later time (Preston & de Waal, 2002). Fight-or-ight activation can lead to a privileging of self-needs over relationship needs, while numbing and avoidance can lead to the inability to repay the favor. These types of moral exchanges can lead to damaged relationships and negative spirals of family interactions. A chimp who helps a friend retrieve food but is not paid back in kind can exhibit negative social behavior as a consequence, including refusing support or food or moralistic aggression. In this way, a traumatic event occurring to a family member may lead to second-order change in the stability of the family system’’s structure. PTSD is a normal reaction to abnormal life events. Even families with effective emotional regulation strategies are often not adequately prepared to support a loved one with trauma symptoms. Resiliency factors plus effective emotion regulation and secure family attachment can mitigate the risk of developing PTSD and aid in the treatment of trauma (Walsh, 2007). Developing Family Resilience There are multiple factors that improve families’’ ability to respond effectively to overwhelming stress (Hoge, Austin, Pollack, 2007; Walsh, 2007). Some elements of resiliency are: Intrapsychic factors within family members (e.g., emotional regulation skills, openness); Transactional patterns within the family (e.g., providing emotional support, decoding emotional reactions, normalizing and validation); Extended family system and friends (e.g., supporting the affected family members or indirectly affected family members, monetary support, practical support, problem solving); Mesosystemic factors, like churches and schools (e.g., contact with religious gures, support networks, problem-solving). Trauma theory is a salutagenic, not pathogenic, model. While many individuals who experience traumatic events develop PTSD, many more do not (Bonanno, Galea, Bucciarelli & Vlahov, 2007). Understanding the family factors that increase resilience can support clinicians in developing effective family interventions.
  3. 3. 5Spring/Summer 2012 emotional interactions (Smith & Ellsworth, 1985). This process results in a powerful opportunity for individuals to develop new patterns of emotional interactions and can be applied in family therapy. Four key mechanisms identied by Schore (2001) that lead to increased effective implicit interactions are: Rupture-and-repair cycle: Small relationship ruptures are followed by reconciliation and implicit attunement; Decoding empathy cycle: Emotionally matching children’’s affective state is followed by decoding children’’s experiences that are tied to this affect, and then re-attuning the affective state to match any shifts in children’’s emotions; Implicit boundary setting: The most obvious form of this type of boundary setting is ““the look”” parents give to children, which lets children know that they are pushing their parents’’ limits; Modeling emotion regulation: Opportunities for corrective emotional modeling for both parents and children are provided via limbic system training. Implicit Family Therapy Interventions to Increase Resiliency PTSD affects multiple dimensions of family functioning. One of the underexplored aspects of family therapy is the impact of a fast circuit or implicit emotion co-regulation on a family. Therapists can develop skills to recognize implicit emotional exchanges, develop effective interventions, and support the development of resilience in the family system. Examples for the major domains of implicit family system interventions are listed below: Tracking skills: Identifying implicit regulation patterns; identifying transitional moments (e.g., when the family is on the verge of entering a destructive pattern); identifying implicit triggers (i.e., watching for the sensory cues leading to affective responses); identifying attunement (e.g., the moments when the family is functioning well); and identifying pro-social emotions (e.g., allowing the therapist to privilege effective interactions shifting the hedonics of interactions); Enactment-based skills: Slowing down the interaction, validation, coaching empathy, changing proximity, and offering physical support; Psychoeducation: Understanding how the ght-or- ight response works, learning about dissociation, seeing the different ways that other family members express love, and valuing the importance of play; Home practice: Playtime, quiet time, argument pauses, and time to appreciate the efforts of other family members. Conclusion Increased psychological distress in a family member creates profound alterations in family interactions (Walsh, 2007). The majority of individuals will at some point be affected, if only for a brief time, by a traumatic event, and unregulated symptoms of trauma can affect generations to come. Understanding the impact of implicit emotional regulation can lead to developing effective tools to increase family functioning and support a family to aid in the resilience of individuals with symptoms of PTSD. References Bechara, A., Damasio, H., Tranel, D., & Damasio, A. R. (2005). The Iowa gambling task and the somatic marker hypothesis: Some questions and answers. Trends Cognitive Science, 9(4), 159-162. Betancourt, T. S., & Khan, K. T. (2008). The mental health of children affected by armed conict: Protective processes and pathways to resilience. International Review of Psychiatry, 20(3), 317-328. doi: 10.1080/09540260802090363 Bonanno, G. A., Galea, S., Bucciarelli, A., & Vlahov, D. (2007). What predicts psychological resilience after disaster? The role of demographics, resources, and life stress. Journal of Consulting and Clinical Psychology, 75(5), 671-682. doi: 10.1037/0022- 006X.75.5.671 Hog, E. A., Austin, E. D., & Pollack, M. H. (2007). Resilience: Research evidence and conceptual considerations for posttraumatic stress disorder. Depression and Anxiety, 24(2), 139-152. doi: 10.1002/ da.20175 Knyazev, G. G., Slobodskoj-Plusnin, J. Y., & Bocharov, A. V. (2009). Event-related delta and theta synchronization during explicit and implicit emotion processing. Institute of Physiology, Siberian Branch of the Russian Academy of Medical Sciences, Retrieved from http://dx.doi.org/10.1016/j.neuroscience.2009.09.057. McCubbin, M., Balling, K., Possin, P., Frierdich, S., & Bryne, B. (2002). Family resiliency in childhood cancer. Family Relations, 51(2), 103- 111. doi: 10.1111/j.1741-3729.2002.00103.x. Norris, F. (1992). Epidemiology of trauma: Frequency and impact of different potentially traumatic events on different demographic groups. Journal of Consulting and Clinical Psychology, 60(3), 409- 418. doi: 10.1037/0022-006X.60.3.409 Ochberg, F. (1988). Post-traumatic therapy and victims of violence. (pp. 83-110). New York, NY: Brunner/Mazel. Porges, S. (2007). The polyvagal theory: New insights into adaptive reactions of the autonomic nervous system. Cleveland Clinic Journal of Medicine, 72(2), S86-S90. doi: 10.3949/ccjm.76.s2.17 Preston, S. D., & de Waal, F. B. M. (2002). Empathy: Its ultimate and proximate bases. Behavioral Brain Sciences, 25(1), 1-20. Schore, A. (2001). The effects of early relational trauma on right brain development, affect regulation, and infant mental health. Infant Mental Health Journal, 22(1-2), 201-269. doi: 10.1002/1097- 0355(200101/04)22:1<201::AID Smith, C. A., & Ellsworth, P. C. (1985). Patterns of cognitive appraisal in emotion. Journal of Personality and Social Psychology, 48(4), 813-838. doi: 10.1037/0022-3514.48.4.813 Szapocznik, J., Hervis, O., & Schwartz, S. (2003). Therapy manuals for drug addiction: Brief strategic family therapy for adolescent drug abuse. Washington, DC: National Institute of Drug Abuse. (NIH 03-4751) Retrieved from http://archives.drugabuse.gov/TXManuals/ BSFT/BSFTIndex.html Rauch, S., Whalen, P., Shin, L. M., McInerney, S. C., Macklin, M. continued on p. 8
  4. 4. 8 Trauma Psychology Newsletter seize young children without regard for their will and without standing to object, and send them to be battered. This can be stopped if psychologists are willing to step forward to create and enforce specialized rules to apply to these cases. Where children’’s rights are denied and they are sent to live with batterers in contravention of their 4th amendment right under the US Constitution, ““To be secure in their persons, houses, papers, and effects,”” and the good parent is then deprived of protecting their child, I blame the courts. I also fault the professionals involved, because even where the laws are on the books and the guidelines are in place, they cannot be properly implemented where there is no real accountability by the professional organizations of the experts who testify. Psychologists can implement procedures and regulations that licensees must follow and they can be required to report all limitations in their expertise to the court before undertaking any court appointment or private appointment. Perhaps they can be required to take an additional test post licensure in special areas of practice before they are permitted to testify. There are social and cultural assumptions that need to be overcome in pursuing all claims, and psychologists properly trained can assist with these as well. For example, protective parents who bring the issue of abuse to the attention of a court are sometimes accused of attempting to get ““a leg up”” in a divorce or custody matter by raising child abuse. Where the protective parent comes under scrutiny and the perpetrator named by the child is allowed to attack him/ her, the court unwittingly exacerbates the abuse. I have come to believe that the change we need cannot be won in the courts on a case-by-case basis alone. No single story tells the world what parents trying to protect their children are facing daily in courts across the country. Protective parents are losing their children in custody cases while perpetrators gain the court’’s imprimatur to continue to abuse. The news media rarely cover abuse or custody cases unless there is a death. Their legal departments shy from these cases, assuming them to be ““he said she said”” stories. There is an expectation that if the court believed a child was abused, it would protect the child. After all, we live in a country that believes in and relies on its system of justice, so we assume justice must have prevailed or a bad parent would not have the custody of the children. Psychologists can hold members of their community accountable by creating community standards for expertise in child custody matters where child protection is involved. Because of the difculty in holding psychologists accountable to ethical guidelines for custody evaluations, should licensing boards establish special standards of knowledge psychologists must meet before providing expert testimony regarding children? This would make it more difcult for unscrupulous psychologists to claim they are experts in child abuse. Perhaps there should be a separate license for forensic psychology, as there is for school psychology, with recognition for specialty in areas such as domestic violence and child abuse and where testimony in these specialty areas is prohibited absent specialized training in these specialized areas. While licensed psychologists may already be required to maintain the most current knowledge, perhaps there could be a way to require and enforce psychologists’’ obligation to disclose the limitations of their training and experience to the court, and to require that they refuse to opine on any issue where they have not been specially trained. Our children deserve nothing less. Toby Kleinman is a NJ attorney and has consulted in over 45 states. She is an Associate Editor of The Journal of Child Custody, has published articles in The New Jersey Law Journal, taught at the Harvard School of Public Health, is a director of the Leadership Council on Child Abuse and Interpersonal Violence, served as the Professional Liaison to Division 56, is on the Board of Advisors of the DV Leap at GW Law School. Ms. Kleinman has presented at IVAT, AFCC, the Battered Mothers Custody Conferences as a keynote speaker, and has trained family court judges. Ms Kleinman has also been voted a New Jersey Super Lawyer and is called as a guest expert on network television. L., Lasko, N. B., Orr, S. P., & Pitman, R. K. (2000). Exaggerated amygdala response to masked facial stimuli in posttraumatic stress disorder: A functional MRI study. Biological Psychiatry, 47(9), 769- 776. van der Kolk, B. (2006). Clinical implications of neuroscience research in PTSD. Annals of the New York Academy of Sciences, 1071, 277- 293. doi: 10.1196/annals.1364.022 Walsh, F. (2007). Traumatic loss and major disasters: Strengthening family and community resilience. Family Process, 46(2), 207-227. Westen, D. (2000). Commentary: Implicit and emotional processes in cognitive-behavioral therapy. Clinical Psychology: Science and Practice, 7(4), 386-390. doi: 10.1093/clipsy.7.4.386 Zajonc, R. B. (1984). On the primacy of affect. American Psychologist, 39(2), 117-123. doi: 10.1037/0003-066X.39.2.117 Michael Changaris, PsyD, incorporates trauma theory into his work with families and children in Northern California. He also integrates affective neuroscience with evidence-based treatments, conducts trainings on mindfulness, and provides psychotherapeutic treatment for elders and families addressing end-of-life issues. Effects of Trauma on Implicit Emotion Regulation Within a Family System continued from p. 5