Treatment approaches to intergenerational trauma

Historical trauma

One of the challenges common to the various treatments of historical trauma is the difficulty in forming an alliance with the survivors. This should be kept in mind when reflecting on the protocols listed below.

Holocaust survivors: According to Kellerman (2001), Holocaust survivors in Israel do not want to be treated as psychiatric patients. Whilst acknowledging that there is a dearth of research in treating Holocaust trauma he discusses a number of aspects of treatment as offered by the AMCHA, 'National Israeli Center for Psychosocial Support of Survivors of the Holocaust and the Second Generation'. Treatment approaches and techniques vary according to age, status as an adult or child survivor etc. A draft of this paper can be foundhere.

Native Americans: Brave Heart (1998) conducted research on a 4-day psychoeducational intervention aimed at 45 Lakota human service providers. She found that as individuals became more informed about the nature of historical trauma, they became better able to understand its impact and association with emotions such as grief. Contexts such as the one provided by Dr Brave Heart can function as fora where powerful stories, songs, histories and strategies for resilience can also be shared, initiating or reinforcing the intergenerational transmission of resilience (Denham 2008).

Aboriginal communities: Atkinson and Ober (1995) established the We-Al-Li Workshops. Their treatment protocol involves equipping a core group of members of the community with the skills to assist vulnerable people in overcoming violent, unlawful or self-destructive behaviours. These authors highlight the difficulty in establishing a working relationship between a potentially distant indigenous community and a service provider who may be initially treated in a mistrustful way. A summary of the tasks and activities of such a group can be found in Atkinson et al. (2010) and also here and here.


Afro-Caribbean communities

Dr Aileen Alleyne (2004, 2005) emphasises treating the "enemy within", which she defines as an intergenerationally transmitted ego structure that prioritises pathological relationships with white people as a potentially primary determinant of self-organisation. She recommends that when working with individuals or communities there is a need to recognise pathogenic scripts emanating from the enemy and their effects, reframing these self-defeating scripts, exploring personal agency, and making space for personal rights. She stresses highlighting strengths and defining identity in ways unrelated to white people. Differentiation between what belongs to the self and the other can heal ego-splits and prevent acting out based on projected aggression.

Joy Angela LeGruy (2005) introduced the concept of post-traumatic slave syndrome. She explores in depth adaptive behaviours prior to slavery and analyses current maladaptive behaviours of contemporary African Americans. A core aspect of her treatment recommendations involves the healing of "vacant esteem" (associated with feelings of hopelessness, anger and manifests outwards in destructive and self-destructive behaviours) through the adoption of pre-slavery values.

Omar Reid, Sekou Mims and Larry Higginbottom (no date) in the USA recommend a holistic treatment program for post-traumatic slave syndrome that is specifically designed to be sensitive to the cultural needs of African-American individuals. This package involves a group-based stage-approach to treatment starting with abstinence from substances and the teaching of a meditation that includes a ritual commemoration of the individual's ancestry. The next stage, as in LeGruy's work, involves drawing from pre-slavery coping mechanisms to build a repertoire of healthy personal and relational strategies.


Familial trauma

Family therapy / Family systems approach

When thinking about familial trauma we are attempting as much as possible to restrict the definition to families where there has not been a history of disorganised attachment, but that a reasonably secure attached family contains a traumatic pocket due loss, or separation that has not been talked about. As such the specific nature of the unspoken content it is likely to reveal itself only during the course of therapy.

A family systems approach is described by Dyregrov (2014) and includes managing secrets and handling traumatic reminders amongst other interventions. Psychoeducation (for instance gender differences in managing trauma or parent and child differences) involving helpful practices on fact sharing, managing traumatic reminders and accessing to support groups is also a part of this intervention.


Psychodynamic therapy

Psychoanalytic views would generally converge on the hypothesis that something which cannot be thought or talked about is likely to be acted. Like attachment trauma below, working with enactments is likely to be a significant part of the work. These may reveal dissociated interpersonal scenarios that have been "transposed" into the mind of the child and are subsequently played out in the relationship with the adult client. Prophecy Coles (2011) discusses a number of cases involving familial trauma where the unmetabolised content was enacted between therapist and client.


Relational psychoanalysis

Relational Psychoanalysis is a broad church consisting particularly of US clinicians. However, in the UK it has become associated with attachment work and this model has found a home at the Bowlby Centre in London. Some prominent US clinicians who are well known to write about trauma and enactment already mentioned are Bromberg (2006, 2011), Brothers (2008), and Stern (2010). The work of the intersubjectivist Robert Stolorow (2007) combines his evolution of self-psychology with continental psychoanalysis. In terms of applying their work to the area of familial trauma we could hypothesise that the "not me"/dissociated parts of the client related to familial trauma are not as extensive as in early attachment trauma (see below) and enactment not the most habitual occurrence in therapy. However, it is only through enactment that these parts can be known according to these clinicians. The family's idiosyncratic post-trauma relationship amongst its members and with the community, as well the absences created by death or loss, are only likely to become understood once they are contextualised in the therapeutic relationship. The attachment lens can illuminate how the trauma is expressed in the client's movement to and fro the therapist, and the client's own approach or avoidance of ideational content in his or her own mind.


Parent infant psychotherapy (also see in attachment trauma) can be used in a manner of prevention when there is sufficient diagnostic information that the parent has been affected by familial trauma.


Attachment trauma

When we speak of intergenerational transmitted attachment trauma find ourselves in the territory of work with disorganised attachment resulting from significant neglect or abuse due to the caregiver's own disorganisation of attachment (Main & Hesse 1990). The result is usually a global difficulty in thinking, feeling, and forming and maintaining relationships, rather than the more localised or domain specific impairments seen in neurosis. Such work with adults is likely to involve addressing personality difficulties or personality disorder. Therefore, the principles of Mentalization Based Therapy (Bateman & Fonagy 2004, 2006) or Transference Focused Therapy (Yeomans et al. 2002, Clarkin et al. 2015) may be helpful frameworks for clinicians working with individual clients.

Family therapies are likely to be particularly helpful for assisting traumatised children or adolescents. One such example is the Intergenerational Trauma Treatment Model (ITTM) developed in California, USA. Read the protocol here.

For children clients, the Child Trauma Academy in Texas, USA has developed the he Neurosequential Model which translates neuroscientific principles into play therapy. Please find relevant information and papers here.

Another intervention aimed at children is Dyadic Developmental Psychotherapy (DDP), a form of attachment informed therapy developed by Dan Hughes to help children affected by abuse or neglect. It involves both therapy with the child and parenting assistance provided to parents. More information can be located here.

Last but not least, parent infant psychotherapy can be very helpful to mothers who have experienced trauma shortly before or after birth. The advantage of this approach is that it allows for early intervention that can disrupt the possibility of trauma transmission. One such case can be found in the work of Belt et al. 2011, who describe the treatment of a woman affected by the loss of her partner during pregnancy.

Bibliography

Atkinson, J. & Ober, C. 1995, 'We Al-li-fie and water: a process of healing', in K Hazelhurst (ed.), Popular justice and community regeneration: pathways to Indigenous reform (pp. 201-18), Praeger Press, Westport, CN.

Bateman, A & Fonagy, P 2004, Psychotherapy for borderline personality disorder, Oxford University Press, Oxford, England.

Bateman, A & Fonagy, P 2006, Mentalization-based treatment for borderline personality disorder, Oxford University Press, Oxford England.

Belt, R, Kouvo, A, Flykt, M, Punamaki, R, Haltigan, J, Biringen, Z & Tamminen, T 2012, 'Intercepting the intergenerational cycle of maternal trauma and loss through mother-infant psychotherapy: a case study using attachment-derived methods', Clinical Child Psychology and Psychiatry, [online] vol. 18, no. 1, pp. 100-120, available at: [Accessed 19 Oct. 2014].

Brave Heart, M. (1998). The return to the sacred path: Healing the historical trauma and historical unresolved grief response among the Lakota through a psychoeducational group intervention. Smith College Studies in Social Work, [online] 68(3), pp.287-305, available at: http://dx.doi.org/10.1080/00377319809517532[Accessed 19 Oct. 2014].

Bibliography 

Clarkin, J, by Yeomans, FE & Kernberg, OF 2015, Transference-focused psychotherapy for borderline personality disorder, American Psychiatric Publishing, Arlington, VA.

Coles, P 2011, The uninvited guest from the unremembered past, Karnac Books, London, England.

Denham, A. (2008). Rethinking historical trauma: Narratives of resilience. Transcultural Psychiatry, [online] 45(3), pp.391-414, available at: http://dx.doi.org/10.1177/1363461508094673 [Accessed 19 Oct. 2014].

Dyregrov, A (2014), 'Family recovery from terror, grief and trauma', available at:http://earlytraumagrief.anu.edu.au/files/Family%20Recovery%20from%20Terror%2C%20Grief%20%26%20Trauma.pdf

Iyengar, U, Kim, S, Martinez, S, Fonagy, P. & Strathearn, L 2014, 'Unresolved trauma in mothers: intergenerational effects and the role of reorganization', Frontiers in Psychology, [online] vol. 5, available at:[Accessed 19 Oct. 2014].

Kellerman, NPF 2001, 'The long-term psychological effects and treatment of Holocaust trauma', Journal of Loss and Trauma, [online] vol. 6 no. 3, pp. 197-218, available at:http://dx.doi.org/10.1080/108114401753201660 [Accessed 19 Oct. 2014].

LeGruy, J 2005, Post traumatic slave syndrome, Joy DeGruy Publications, Portland, OR.

Schechter, D, Kaminer, T, Grienenberger, J & Amat, J 2003, 'Fits and starts: a mother-infant case-study involving intergenerational violent trauma and pseudoseizures across three generations', [online] Infant Mental Health Journal, vol. 24, no. 5, pp. 510-528, available at: http://dx.doi.org/10.1002/imhj.10070 [Accessed 19 Oct. 2014].

Yeomans, F, Clarkin, J & Kernberg, OF 2002, A primer on transference-focused psychotherapy for the borderline patient, J. Aronson, Northvale, NJ.