What characteristics would lead a provider to suspect domestic violence, child abuse, or elder abuse is taking place within a family

Breaking the Links in Intergenerational Violence: An Emotional Regulation Perspective

JUDITH P. SIEGEL*

The saying “violence begets violence” is an apt descriptor of the cycle of family violence, as children who witness parental violence are at high risk for repeating family violence in their own adult intimate relationships. Neuroscience research suggests that emotional reg- ulation may be an important link in the heritability of family violence, and promotes awareness of the importance of internalizing as well as externalizing responses to stress, neglect, and abuse. This study argues for a trauma-informed approach to identifying chil- dren and parents whose symptoms of emotional dysregulation may be otherwise over- looked, and for an expanded approach to treatment that incorporates family systems and emotional regulation strategies.

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The replication of family violence from one generation to another is a subject of greatconcern. Although factors such as genetics, social learning, and culturally reinforced beliefs have been identified as potential moderators in perpetuating the cycle (Busby, Hol- man, & Walker, 2008; Tolman & Bennett, 1990), research contributions from neurobiology suggest that, like other kinds of trauma, family violence may be related to disturbances in emotional regulation. From this perspective, batterers with impairments in emotional reg- ulation would be viewed as lacking the ability to notice, comprehend, and manage escalat- ing emotions, as well as the skills required to resolve differences and problems in constructive, nonviolent ways. Although interventions that strengthen emotional regula- tion are used in the treatment of PTSD, addiction, and other disorders that are comorbid in populations with family violence, an emotional regulation approach is not typically used in the treatment of batterers, victims, and children who witness parental violence (WPV). This study explores the potential link between disturbances in emotional regulation created by childhood exposure to a family environment that includes witnessing parental violence and the repetition of partner violence in adult intimacy.

A PROBLEM IN NEED OF EXPANDED STRATEGIES

Despite the belief that most American children are provided with ample protection and support, too many home environments fail to recognize the harm that is caused by inti- mate partner violence. Rates of battering are difficult to establish, but are estimated to occur in 30% of families with children (McDonald, Jouriles, Ramisetty-Mikler, Caetano, & Green, 2006; McKinney, Caetano, Ramisetty-Mikler, & Nelson, 2008). Although economic stress and substance abuse may increase the incidence of marital conflict, partner violence occurs across all socioeconomic spheres (Fox, Benson, DeMaris, & van Wyk, 2004). Silvern

*Silver School of Social Work at New York University, New York, NY. Correspondence concerning this article should be addressed to Judith P. Siegel, Silver School of Social

Work at New York University, 1 Washington Square N, New York, NY 10543. E-mail: [email protected]. The author would like to thank Drs. Yitzak Frank and Al Gurman for their comments.

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et al. (1995) reported that 37% of the college students in their sample described being exposed to violence between their parents.

Although research has provided extensive information about the harm created by fam- ily violence, the services offered to families with IPV have not kept pace with emerging findings. They have also, for the most part, failed to demonstrate efficacy in stopping the violence. Reviews of programs for men who batter indicate a high drop-out rate, resistance to change, and poor outcome (Babcock, Green, & Robie, 2004; Eckhardt, Murphy, Black, & Suhr, 2006). Although battered women may receive counseling, the feminist position on partner abuse works against diagnosing the victim, and unintentionally deprives women who have experienced childhood trauma from receiving therapy that targets related prob- lem areas. The failure to recognize multigenerational consequences in areas such as emo- tional regulation ultimately impacts the children who WPV, as they typically do not receive counseling unless severe externalizing symptoms develop.

ESTABLISHING THE HERITABILITY OF FAMILY VIOLENCE

Although there is an established literature documenting childhood exposure to family violence in adults who batter or remain involved in violent relationships, efforts to inter- pret and replicate findings are complicated due to the different kinds and combinations of family violence.

Different Combinations of Exposure and Experience

Children who witness parental violence may be exposed to both female- and male-initiated violence, and situations where one or both parents are abused (Barner & Carney, 2011). Physical abuse is often accompanied by emotional abuse, although not all emotionally abu- sive relationships culminate in violence. However, as partner violence often occurs in the context of escalating conflict, it is probable that WPV children have been exposed to multi- ple episodes of parental discord in addition to those that culminate in violence. Children from those families would be exposed to an additional source of stress, as intimate partner conflict and hostility have been found to harm children even in the absence of abuse (Amato, Loomis, & Booth, 1995; Gottman & Katz, 1989; McNeal & Amato, 1998). Exposure to parental conflict has been shown to increase the likelihood of school and peer problems in young children, and depression and alcohol dependence in young adults (Turner & Kopiec, 2006).

Research on the consequences of family violence has also been handicapped by the vari- ability of abuse (Whitfield, Anda, Dube, & Felitti, 2003). For example, the consequences of exposure to abuse vary according to the child’s involvement, as children may directly witness parental abuse, or become aware of the incident after it has occurred (Garrido, Culhane, Petrenko, & Taussig, 2011). The age of the child, severity of abuse, frequency of abuse, and the role of the child in the postabuse aftermath all contribute to the impact on the child. Graham-Berman and Perkins (2010) suggest that although the age of first expo- sure predicts children’s behavioral problems, cumulative exposure has the most direct influence on externalizing behavior problems. McDonald, Jouriles, Norwood, ShineWare, and Ezell (2000) found that 48% of the families of children referred for outpatient therapy due to behavioral problems reported domestic violence.

To further confound research activity, many children who are exposed to parental violence experience emotional and/or physical neglect and physical abuse at some point during their childhood. Hamby, Finkelhor, Turner, and Ormod (2010) report that one third of WPV youth experienced maltreatment in the same year as the parental violence occurred, and over half of the grown WPV children report exposure to personal abuse by midadulthood. Witnessing in the absence of physical or sexual abuse is considered a form of

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emotional abuse that may lead to difficulty with emotional regulation throughout adulthood and is predictive of adult intimate violence (Burns, Jackson, & Harding, 2010; Holt, Buck- ley, & Whelan, 2008). However, children exposed to multiple forms of family violence have the highest rates of emotional, cognitive, and psychiatric disorders (Garrido et al., 2011).

The Repetition of Abuse

Despite limitations due to difficulty differentiating different kinds and levels of family violence and the imprecise methodology of existing studies (Thornberry, Knight, & Love- grove, 2012), it is apparent that children raised in homes with IPV violence have a greater likelihood of repeating and/or re-experiencing relationship violence in their adult lives. In a study of 45,000 adults in relationships, Busby et al. (2008) calculated that whereas 10% of couples with no family of origin violence were violent in their own relationships, 32% of the couples whose parents were violent repeated violence in their own relationship. Iver- son, Jimenez, Harrington, and Resick (2011) found that witnessing parental violence was associated with a 2.4 increase in repeating IPV and that witnessing IPV was more power- ful than childhood experiences of physical or sexual abuse in predicting IPV. Roberts, Gilman, Fitzmaurice, Decker, and Koenen (2010) report a 2.6 risk ratio between witnessing and perpetrating intimate partner violence, with similar rates reported in women who report IPV (Bensley, Eenwyk, & Simmons, 2003; Forero, 2005). Although Stith, Busch, Lundeberg, and Carlton (2000) challenge reported effect sizes, their meta-analysis of 39 studies supports the premise that growing up in a violent home is significantly related to becoming a victim and/or perpetrating spouse abuse.

CONSEQUENCES OF FAMILY VIOLENCE TO EMOTIONAL REGULATION

There is an extensive body of scholarship that examines how maltreatment and expo- sure to childhood stress can affect brain development and lead to a range of psychologi- cal disorders. Whereas past studies have focused on mood, anxiety, and substance disorders, there is a growing recognition of shared underlying neural dynamics that may explain the tendency toward comorbidity. Kring (2010) suggests that trauma- influenced problems with emotional regulation may manifest in a spectrum of symptoms traditionally categorized as distinct psychiatric disorders. Emotional regulation provides a transdiagnostic perspective that may more accurately identify shared underlying neural impairment.

Neurobiological Consequences of Trauma for Children

The changes in HPA, glucocorticoid, and neuroendocrine systems in children who have witnessed or experienced abuse have been reviewed and summarized in several compre- hensive studies (Cicchetti & Toth, 1995; Cohen, Perel, DeBellis, Friedman, & Putnam, 2002; Gunnar & Fisher, 2006). De Bellis (2001) has reviewed psychobiological and brain maturation studies in maltreated children and suggests that “multiple, densely intercon- nected neurobiological systems are impacted by the acute and chronic stressors associ- ated with childhood maltreatment” (pp. 539). Imaging studies of abused children show a range of malfunctions, including disturbances in frontostriatal circuitry, reduction in brain volume, and reduced white matter in the prefrontal cortex and corpus callosum (Perry, 2009). It is suggested that chronic activation of the HPA system, which is a typical response to exposure to unmitigated stress, influences the production of cortisol and neu- rotransmitters. Brain cells react to these changes by downregulating the number of receptors, resulting in myelination and synaptic pruning that aid immediate survival, but compromise long-term health (Twardosz & Lutzker, 2010). A large body of scholarship

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offers detailed description of disruptions in neural network development created by trauma that ultimately compromise the ability to experience, tolerate, and manage emo- tional states (Briere, 2002; Gunnar & Fisher, 2006; Perry, 2009; Yates, 2007).

NEUROBIOLOGICAL CONSEQUENCES OF CHILDHOOD TRAUMA FOR ADULTS

Whereas there are few fMRI studies on WPV children, several studies have examined adults with PTSD who report exposure to family violence in childhood.

Dissociation, Alexithymia, and Interoception

A growing body of research points to changes in right brain function, particularly in adults with PTSD who, as children, were sexually or physically abused (Van der Kolk, 2003; Van der Kolk, Van der Hart, & Marmar, 1996). Because the right brain regulates affective experience, it is posited that trauma renders these individuals unable to process and regulate intense positive and negative affective states. Overwhelming affect that could not be processed in childhood leads to functional impairments that complicate emo- tional processing in adulthood. Schore (2003) notes that individuals with right brain impairment are compromised in their ability to sense and reflect on changes in subjective self-states. This culminates in a heightened state of overwhelming affect that leads either to an emotionally driven outburst or to dissociative withdrawal.

Other studies emphasize the importance of neural networks that connect different aspects of awareness, memory, and cognition in response to specific triggers (Buchanan, 2007; Barrett, Mesquita, Ochsner, & Gross, 2007). States of heightened arousal in response to perceived danger can lead to neural disconnection that disrupts awareness of emotional turbulence as well as cognitive strategies that might ordinarily help de-escalate arousal (Briere & Spinazzola, 2005; Siegel, 2003). In this instance, a trauma survivor who demonstrates evidence of specific activated neural activity and altered neurobiological markers may be completely cut off from awareness of the emotional state that has been aroused. This lack of self-awareness, known as alexithymia or interoception, has been identified in both survivors of trauma as well as addiction-prone adults (Brunner et al., 2000; Frewen et al., 2008). Zlotnick, Mattia, and Zimmerman (2001) report high levels of alexithymia in adults diagnosed with PTSD and Borderline Personality Disorder, and found that self-assessed severity of emotional and physical neglect in childhood was a more potent predictor of alexithymia than physical abuse.

Dimaggio, Vanheule, Lysaker, Carcione, and Nicolo (2009) view alexithymia as a deficit in the cognitive-experiential processing of emotions that gives rise to dysfunctional responses such as panic, numbness, and violent outbursts. Individuals who shut down in response to heightened emotions are not able to monitor escalating states, and may lose their ability to control aggressive urges in a state of high arousal. Finkel, DeWall, Slotter, Oakten, and Foshee (2009) suggest that violent impulses during conflict interactions are quite common, but are typically regulated once they are recognized; failure to identify aggressive impulses may contribute to the failure to control them.

Neuro-Cognitive Mechanisms

Neuroimaging studies on the cognitive mechanisms involved in emotionally rich mem- ory retrieval also suggest that specific cognitive processes play a role in escalating arousal. For example, splitting, flooding, and rumination work to activate and reactivate memories that have the potential to exacerbate emotional distress. Splitting causes events to be experienced in an extreme form, so that unpleasant events are viewed as “all bad”, whereas enjoyable experiences are idealized (Siegel, 2006). Studies with batterers and

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women who repeatedly return to IPV relationships show high levels of splitting in both populations that statistically distinguish them from nonclinic populations (Siegel & Fore- ro, 2012). Under the influence of splitting, memories of similar events are activated, according to emotional valence to the immediate situation. Neuroscience research on emo- tional memories suggests that positive and negative emotional memories are retained in different neural networks, and when revived, add intensity to the current emotional expe- rience (Suvak & Barrett, 2011). As memory networks are stimulated, similar experiences from the past are remembered, and flood the emotional field in ways that complicate the distinction between past and present.

Although not all children who were abused or witnessed parental violence develop full- blown symptoms of PTSD, these neuro-cognitive changes predispose individuals to a range of disturbances that impact emotional stability as well as interpersonal relationships. The impairments in emotional regulation created by exposure to trauma in early life may have lifelong consequences that contribute to the heritability of family violence.

FAMILY ATTRIBUTES

There are additional aspects of family life related to emotional regulation that should be considered in understanding the heritability of family violence. These include disrup- tions in attachment, compromised parenting in response to the consequences of current and past family violence, and aspects of family relatedness that play a role in establishing emotional well-being in children.

Insecure Attachment Patterns

The importance of attachment patterns between family members has been extensively researched in families who experience trauma. Children who are not securely attached are more likely to develop neural impairments in response to states of emotional dysregu- lation created by exposure to trauma (Fishbane, 2007). Children who lack healthy attach- ment are more prone to difficulty being soothed, have more behavioral disturbances, and are at greater risk for developing addictive problems (Hesse, Main, Abrams, & Rifkin, 2003). Toddlers in secure attachment relationships are able to tolerate stressful situations without the cortisol elevation that is produced in children from insecure attachment rela- tionships (Granath et al., 2006). Research based on adult attachment has demonstrated that the mother’s attachment style predicts the attachment style of her offspring (Fonagy, Steele, & Steele, 2008). Given the heritability of abuse, it is not surprising that the meta-analysis of maltreating and high-risk families shows an overrepresentation of disor- ganized and insecure attachment patterns (Cyr, Euser, Bakermans-Kranenburg, & van Uzendoorn, 2010).

The quality of attachment in the parent–child bond is largely determined by the par- ent’s ability to attune to a child’s needs and provide a stable, nurturing, and protective response. As a secure attachment is important in establishing trust, children with anx- ious, avoidant, or disorganized attachment are less likely to develop secure intimate rela- tionships in adulthood (Fosha, 2003). This may contribute to escalated aggression between partners, as Monson, Fredman, and Dekel (2010) have identified the importance of perceived safety and trust as a cognitive moderator to aggression in intimate relation- ships.

Unhealthy attachment patterns are more prevalent in men who perpetrate IPV, with insecure attachment being particularly problematic (Kesner & McKenry, 1998). Men with avoidant attachment styles and borderline personality disorder are also at high risk for perpetuating IPV (Mauricio, Tein, & Lopez, 2007). Impaired attachment and a history of WPV are related to aggression and abuse in adolescent dating, with anxious attachment

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predicting boys’ aggression and anxious and avoidant anxiety moderating girls (Grych & Knsfogel, 2010).

A family systems approach allows attachment to be seen not only as a relationship func- tion between caretaker and child that predisposes the child to inherit a level of trust in intimate dependency but as a dynamic that influences all family members in the system. Caffery and Erdman (2000) draw on the work of Byng-Hall to suggest that unmet attach- ment needs of one family member affects the way that attachment needs in others can be met. Parents who feel threatened by rejection or family violence may be too preoccupied with securing their own attachment needs to focus on their child. It is also possible that unmet attachment needs in a parent who endures IPV may be displaced onto the parent– child relationship in ways that create parentification or triangulation.

Compromised Parenting

Gottman and Katz (1989) and Siegel and Hertzell (2004) have reviewed parenting prac- tices that help create secure attachment and emotionally stable children. Not surprisingly, the parenting strengths that are highlighted require that parents be emotionally attuned and able to tolerate a range of emotional states in themselves and other family members. Conversely, parents who are preoccupied with personal problems or highly reactive are not able to fully attend to their young children. Given that parents who engage in family violence have a high incidence of comorbidity with diagnosable emotional disorders, they may be compromised in their ability to provide the aspects of parenting that are most valuable in influencing healthy emotional development (Morris et al., 2007). For example, many women who have been battered suffer from PTSD and depression. Graham-Berman, Gruber, Howell, and Girz (2009) found that three quarters of their sample of mothers housed in a domestic violence shelter were significantly depressed. Both PTSD and depression have been associated with impaired parenting and higher levels of adjustment problems in children (Downey & Coyne, 1990; Ashman et al., 2002). Although symptom- atic women may recover once physical violence has ceased, women who experience psycho- logical abuse have long-standing problems with PTSD, anxiety, and depression that do not abate (Blasco-Ros, Sanchez-Lorente, & Martinez, 2010). Men who batter have high levels of comorbidity with substance abuse, PTSD, depression, anxiety, and personality disorders (Klosterman et al., 2010; Turner & Kopiec, 2006).

Although it is relevant to acknowledge the symptoms associated with diagnosable emotional disorders, a family perspective shifts the focus from the individual to the spe- cific ways that impaired emotional processing can affect parenting. Adults who struggle with emotional disorders are invariably compromised in their ability to parent, particu- larly with regards to modeling and coaching emotional regulation skills. For example, depression typically creates emotional withdrawal, irritability, and a negative perspec- tive. It is not surprising that depressed mothers are less playful and more critical of their offspring (Goodman & Gotlib, 1999). Depressed mothers are less able to provide consis- tent maternal warmth, a dynamic that is recognized as an important buffer against the harm of exposure to trauma (Gagne, Drapeau, Saint-Jacques, & Lepine, 2007; Granath et al., 2006).

Parents with PTSD may become emotionally reactive and enraged by events that are not understandable to family members who do not share the same repertoire of emotion- ally tinged triggers, and in a state of heightened anxiety, would become unable to focus on a child’s needs. Parents who are inebriated or substance impaired are less able to attend to parenting responsibilities (Forrester & Harwin, 2011; Kelley et al., 2010). Their chil- dren may also be called upon not only to manage their own physical and emotional needs but to provide care for younger siblings or even for the parents whose abuse has compro- mised their ability to function.

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Intimate relationships with IPV do not produce happy parents. Given their own lack of security and fulfillment, parents who are battered may be preoccupied and overwhelmed with stress that translates into more irritability and less patience with misbehaving chil- dren. Harsh parenting is more likely to occur in families with family violence, and is a time-varying predictor in mothers who are involved in IPV (Kim, Pears, Fisher, Connelly, & Landsverk, 2010). Research has noted that harsh, cold, and inconsistent parenting is related to higher levels of aggression in children, and more likely to occur to highly stressed, unstable families (Tracy & Johnson, 2006). It has also been noted that harsh par- enting may disrupt the development of security and self-regulatory skills in children (Bradley & Corwyn, 2008).

Thus, the impairments in processing and tolerating emotions that underlie comorbid disorders and marital dissatisfaction in adult populations with IPV may contribute to parenting limitations that ultimately compromise resilience and the development of emotional processing skills in their offspring (De Bellis, 2001). Given their own symptoms of distress, they are less able to provide the warmth, attunement, and stability required for optimal child development (Davidson, 2000; Stroufe, 2000).

System Dynamics

A systemic perspective of the heritability of family violence also recognizes dynamics that may cause children to be reacted to or placed in family roles that work against ideal emotional development (Gagne et al., 2007; Struge-Apple, Skibo, & Davis, 2012). When adults who are not able to self-soothe turn inappropriately to their offspring for comfort, the children are promoted into roles with responsibilities that preclude age-appropriate needs, or the expectation that their needs will be noticed or responded to by others (Hooper, 2007). It is not uncommon for children to attempt to protect a parent who is being threatened or victimized (Amato et al., 1995; Cummings & Davies, 2010). Unfortunately, children who conclude that a parent is not capable of self-protection will not easily trust that parent to provide protection to them. Children who witness parents demonstrating uncontrolled aggression may also experience vicarious identification that changes their level of trust and security toward the aggressive parent. Their beliefs about respect, trust, and conflict resolution, current and future, all become endangered (Crawford & Wright, 2007; Siegel, 2000).

Children who are raised with family violence may be triangulated into their parents’ intimate relationship, leading to unhealthy alliances and a tendency toward self-blame (Grych, Raynor, & Fosco, 2004; Kerig & Swanson, 2010). WPV children may also experi- ence parental rejection or spillover aggression subsequent to parental conflict. Margolin (2004) has found that families reporting interparental aggression show lower levels of father-to-child empathy and higher levels of mother-to-child negative affect following hostile marital conversations. Rejection has been identified as an important emotional disregulator (Eisenberger & Lieberman, 2004), and may undermine the emotional climate that is required to build self-esteem.

The Emotional Climate

Morris et al. (2007) speak about the importance of the emotional climate that domi- nates the family atmosphere. Although most young children who are exposed to parental conflict become tense and emotionally aroused (Cummings & Davies, 1994), family cohe- sion and a sense of safety can mediate against the adverse consequences of IPV (Owen, Thompson, Shaffer, Jackson, & Kaslow, 2009). Cummings and Schatz (2012) stress the importance that emotional security has on child development, and cite the elevated risks for children raised in homes with distressed marriages. Although the bulk of their

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research focuses on security as an emotional regulator, it is also possible that children exposed to parental conflict or who WPV experience emotional disruption in the form of trauma contagion. Therapists who work with trauma victims note that family members of individuals with PTSD may acquire trauma symptoms as a form of emotional contagion or by-product of constant exposure (Nelson & Wampler, 2007; Sautter, Glynn, Thompson, Franklin, & Han, 2008; Dinshtein et al., 2011). Thus, exposure to persistent, heightened negative emotion in the family may weaken resilience and compromise emotional development in the children.

INTERVENTIONS

Current Approaches to Batterers, Victims, and WPV Children

Despite the fact that family violence occurs between family members, prevailing treat- ment interventions are delivered, for the most part, to individuals, or groups composed of nonfamily members. Men who initiate IPV are typically referred to batterer intervention programs that provide group psycho-education or cognitive-behavioral strategies. In a recent analysis of programs for children exposed to IPV, only two studies included fathers, and both delivered psycho-educational interventions emphasizing the harm inflicted on offspring (Rizo, Macy, Ermentrout, & Johns, 2011).

More extensive services exist for abused women with children, but interventions tend to provide support through individual or group sessions, with additional parenting education offered in some agencies (Graham-Bermann & Hughes, 2003; Rizo et al., 2011). Although treatment offers support and ways to strengthen competency and resilience, political concerns have influenced the exclusion of therapies that target diagnosable disor- ders such as anxiety and depression.

Children who have been identified as being traumatized by WPV may be referred to individual or group treatment, but due to a general lack of awareness of the damage cre- ated for children who witness, they are only referred in response to pronounced externaliz- ing symptoms (Jouriles et al., 2001). This is a major point of concern, as internalizing and dissociative symptoms are just as prevalent in traumatized children, and are less likely to be identified as indicators of trauma (Siegel, 2012). Although disorders that develop in adulthood can be linked to internalizing symptoms (Cloitre, Miranda, Stovall-Mclough, & Han, 2005), only the children who display disruptive aggressive behavior or conduct dis- order receive treatment.

Alternative Treatment Approaches

The scarcity of interventions that are based on emotional regulation is not related to the availability of models that have demonstrated promising results in individual, family, and group treatment approaches with other trauma-related problems.

Dialectical behavioral therapy

Dialectical Behavioral Therapy (DBT) has been used successfully in group and individ- ual interventions with individuals diagnosed with substance abuse as well as those who have borderline personality disorder (Linehan, 1993; Robins & Chapman, 2004). DBT provides attunement, validation, and mindfulness techniques that help individuals acknowledge and tolerate stressful emotional states while finding ways to de-escalate and work more productively with triggers. This enhances the ability to process emotional information related to self or others, and reflect on emotional information instead of acting out (Baird et al., 2005; Levine et al., 1997).

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Mindfulness

Mindfulness has been found to help individuals who struggle with personality disorder, aggressive behavior, and substance abuse (Baer & Huss, 2008; Burke, 2009). Mindfulness strategies include learning to become grounded by focusing on bodily sensations in the moment. Participants learn to accept sensations, thoughts, and physical experiences with- out judgment. The ability to be fully engaged in the moment with heightened observation has been found to reduce anxiety and emotionally charged reactions to past events and future worries. Mindful strategies have achieved therapeutic benefits in a range of settings that work with adult populations (Davis & Hayes, 2011; Keng, Smoski, & Robins, 2011) as well as children (Coholic & LeBreton, 2009; Greenberg & Harris, 2012).

Yoga and breathing strategies

Yoga and breathing interventions have also been used to reduce symptoms of PTSD, anxiety, and depression. Brown and Gerbarg (2005) have advocated the use of yogic breathing in the treatment of stress-related disorders and PTSD, and contributed to a suc- cessful intervention offered to trauma survivors of the South-East Asia tsunami (Descilo et al., 2010). In a randomized study comparing stress reduction in employed adults, yoga was found to be equally effective as cognitive-behavioral therapy in reducing symptoms of stress (Granath et al., 2006).

Integrated approaches to individual trauma survivors

Affect regulation techniques are fundamental to several established psychotherapeutic approaches to trauma survivors, such as ATRIUM (Miller & Guidry, 2001), BEAR (Hore- nczyk, 2012), Seeking Safety (Cohen et al., 2002; Najavits, 2002), and TARGET (Ford, Albert, & Hawke, 2009). Models incorporating emotional regulation techniques are also proving effective in the treatment of aggressive children who have been traumatized (Saxe, Ellis, & Kaplow, 2007). Although a discussion of the differences among these approaches is beyond the scope of this study, each provides strategies to improve aware- ness and tolerance of emotions through exercises such as measuring emotional states, learning to identify feelings, and working with breathing to recover from dysregulation. Cognitive strategies are often employed to challenge underlying beliefs and revived memo- ries that escalate emotional arousal. Victims may also be encouraged to rework the trauma narrative to erase self-blame.

Integrated approaches to traumatized families

A number of parenting interventions incorporating attachment and emotional regula- tion principles have been developed for children at high risk of parental neglect or abuse (Beebe, 2010; Slade, 2006). Some of these approaches emphasize the importance of attune- ment between parents and young children, and include shared viewing of taped inter- actions to help parents ‘see’ and understand their children from a different perspective. Behaviors that may have triggered harsh or rejecting responses from parents become neutralized as parents learn new ways to soothe and respond to their children.

Parenting strategies are also incorporated in work with families whose children have been exposed to combat. Through sessions with dyads consisting of mother and child, father and child, and the parents together, the therapist is able to observe how the child’s behavior changes in the presence of each parent. It also allows the therapist to note parenting behaviors and interactions that may be camouflaged in a wider family environment or concealed in parenting sessions that rest entirely upon the parents’ self-report (Harel & Jochanan, 2012; Van Horn and Lieberman, 2009). Interventions focus on improving the attachment bond between caretakers and children by raising

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attunement, strengthening mentalizing functions, and generating interparental support. In play activities with the child and parent, the therapist is able to ask each parent how he/she understands their child’s behavior at any given moment. Parents who demon- strate discomfort with a child’s play theme may be struggling to control similar emotions in themselves that have not been addressed (Hesse et al., 2003). Through facilitating awareness and opportunities to discuss shared emotional memories, families are able to process and integrate provocative material that may otherwise remain diverted or repressed.

Family models have also been used for couples who struggle with PTSD. Beardslee et al. (2011) and Dekel and Monson (2010) help couples understand heightened emotional responses to triggers that are not shared or understood by partners who have not experi- enced combat. Helping partners learn to speak openly and relate in ways that restore connection have reduced emotional reactivity and levels of stress. Couples with childhood abuse have also been helped through dyadic interventions (Maltas & Shay, 1995; Siegel & Geller, 2000). Most recently, Emotion-focused therapy has been found helpful for dis- tressed couples that include a partner with a history of childhood abuse (LeBow, Cham- bers, Christensen, & Johnson, 2011).

DISCUSSION

In an era of burgeoning treatment options for traumatized individuals, couples, and families, the victims and perpetrators of family violence are typically deprived of strate- gies that have proven useful to others. This remains so despite attempts to generate inter- est in the efficacy of DBT and mindfulness, models that have prevailed in the treatment of other trauma-related disorders. It has been over a decade since Fruzzetti and Levensky (2000) provided a rationale and description of ways to implement DBT in treatment of batterers. The Mindful approach to batterer treatment proposed by Rathus, Cavuoto, and Passarelli (2006) has also been neglected despite promising results in reducing emotion- ally based aggression.

Couples with IPV are rarely seen in conjoint treatment, even though the rationale and indications for efficacy have been repeatedly stated (Fals-Stewart & Clinton-Sherrod, 2009; Stith & McCollum, 2011; Stith, Rosen, & McCollum, 2003). Goldner (1998) argued that it was possible to work effectively with IPV couples without endangering the victim or obscuring the perpetrator’s responsibility to end the abuse. Despite her observations that these couples are ensconced in a powerful connection that can only be addressed through conjoint sessions, providers who offer counseling for IPV have not embraced a couples format. Goldner also noted that many IPV couples refuse therapy unless they can be seen together. DeBoer and colleagues suggest that many of the couples who are referred to the traditional group therapy option decide to pursue couples therapy on their own and conceal the abuse from the therapist (DeBoer, Rowe, Frousakis, Dimidjian, & Christensen, 2012; McCollum, 2012).

Proponents of the traditional approaches cite concerns about ensuring the safety of the victim, as well as obscuring the batterer’s responsibility for assaultive behavior that is too frequently blamed on the victim. However, critics of existing services note that beyond safety concerns, stagnation in the field of family violence has more to do with politics and turf protection (Dutton & Corvo, 2006).

As a result of this exclusionary stance, the potential efficacy of emotional regulation interventions in the interruption and prevention of intergenerational family abuse remains speculative. However, in light of the mounting evidence of the effects of trauma on emotional regulation, it is time that family therapists give more consideration to this perspective in their treatment and research activities.

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Given recent research findings, some forms of family violence may be viewed as an out- come of emotional dysregulation created by exposure to family violence, as well as a condi- tion that creates problems with emotional regulation in children who witness, and thus perpetuates the chain of intergenerational family violence. Accordingly, efforts to provide treatments that strengthen security and improve family emotional regulation could serve as a vehicle of prevention, particularly to WPV children who internalize their distress.

Interventions that help family members explore and tolerate emotional reactions can be implemented in individual, couple, family, or couple-group approaches that uphold a systemic view of IPV. Although all approaches to IPV must assess the potential for vio- lence and ensure that the victim is protected from harm, conjoint sessions would allow the therapist to witness and intervene in the specific dynamics that lead to escalating emo- tions. Therapists who recognize the importance of emotional regulation can help the cou- ple become aware of physical indicators of emotional arousal and learn ways to downregulate emotional tension. Systemic exploration of emotional dysregulation would also allow for identification of the triggers that produce emotional reactivity and the meaning that is attributed to a partner’s communication. Although techniques that address splitting, flooding, and rumination have not yet been tested in a couples format, they have proven helpful to women who return to IPV relationships (Siegel & Forero, 2012).

Parents with IPV enact and create disruptive dynamics that are particularly harmful to children who witness. Given the growing consensus of the importance of emotional reg- ulation to psychological health, interruption of family dynamics that disrupt emotional regulation should become the domain of all therapists (Southam-Gerow & Kendall, 2002). Of particular importance is the need for professionals who work with WPV children to become more familiar with the spectrum of symptoms of emotional dysregulation so that children who internalize can receive early intervention. Therapists who work with indi- viduals or couples who report high levels of conflict should routinely assess for IPV. They should also consider ways of expanding the treatment focus to include the children. This may lead to work on emotional coaching and/or more consistent and affectionate parenting approaches. At minimum, parents can be helped to think about the effect of the conflict on their children, and invited to share memories of their own exposure to parental discord to strengthen awareness and sensitivity.

All family members can benefit from learning to process their emotional responses in more adaptive ways. Interventions that help family members tolerate and explore emotional reactions, challenge disruptive cognitive processes, and promote attunement through enhanced communication are options that can be offered in conjoint family ses- sions, or with different constellations of family members. Although litigated batterers are mandated to agency programs that typically do not include strategies for emotional regu- lation, other family members may benefit from a more inclusive range of therapies. Given the large numbers of families with IPV, and the relatively small number that seek help through the courts or agencies identified as providing abuse treatment, it is likely that many family therapists are already treating couples and families who struggle with the potential or aftermath of abuse. Whereas abuse is a serious issue that needs to be properly screened and monitored, treatment options need to expand to meet the needs of families in distress.

It is understandable that clinicians who provide services to battered women and their children must attend to the most pressing needs and are restricted by heavy case loads and limited resources. It may also be challenging for therapists to access information regarding previous violence given the tendencies for many trauma victims to minimize events that are too painful to process (Tracy & Johnson, 2006). However, whether partner violence is suspected or confirmed, past or present, all family members can be provided

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with opportunities to develop the stability that comes with enhanced emotional regulation. Techniques that strengthen emotional regulation may provide an important protective function to those caught in the cycle of abuse, and help reduce emotionally related aggression and its consequences for all family members. When family violence is viewed through a systemic lens that highlights emotional regulation, there are ample opportunities to break the links.

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