PTSD research paper

The role of relationships and families in healing from trauma

Gabriela López-Zeróna and Adrian Blowb

The effects of trauma and its treatment have a central role in health dis- cussions in that trauma exposure is associated with an array of mental health issues, including depression, anxiety, and substance abuse. Treat- ment approaches are varied, but most empirically based protocols are individually focused, targeting intrapersonal difficulties. Although these protocols are critical, they do not directly address the relationship diffi- culties that may arise for survivors. In addition, limited empirical evi- dence supports using systemic approaches in trauma treatment. This article addresses this issue by summarizing the most salient individual and relational evidence-based trauma protocols and by providing a description of common factors among these approaches, while also chal- lenging the field to generate more research that emphasizes systemic interventions as a core consideration in treatment. A case study is included to illustrate the global relevance and benefit of systemic trauma approaches.

Practitioner points • Trauma should be treated as an event that affects everyone in the family and is nested in societal and cultural contexts.

• Close relationships can maintain or exacerbate problems, but they can also be a powerful source of healing.

• Systemic protocols that not only address intrapersonal difficulties, but also focus on survivors’ relationships are critical for healing in the aftermath of trauma.

Keywords: trauma; evidence-based practices.

a Doctoral student in the Couple and Family Therapy Program, Department of Human Development and Family Studies, Michigan State University, Room 408, Human Ecology Building, 552 West Circle Drive, East Lansing, MI 48824, USA. E-mail: [email protected].

b Associate Professor, Couple and Family Therapy Program, Department of Human Development and Family Studies, Michigan State University.

VC 2016 The Association for Family Therapy and Systemic Practice

Journal of Family Therapy (2017) 39: 580–597 doi: 10.1111/1467-6427.12089

The concept of trauma has received a great deal of clinical and research attention over the past few decades. Globally, exposure to trauma is a chronic problem, as many individuals are exposed to at least one traumatic event over the course of their lifetime. Traumatic exposures can occur in a number of contexts including war, family or intimate relationship violence, motor vehicle accidents, natural disasters and criminal events, or through life-threatening illnesses. Millions of individuals worldwide are affected by the aftermath of exposure to a traumatic event (Breslau, 2009).

Even though there is a growing body of research on the interperso- nal effects of trauma, most of the treatment focuses on the individual who directly experiences the traumatic event (van der Kolk, 2003) and there is scant research assessing the outcomes of trauma treat- ment of couples and families (Lebow and Rekart, 2013). Although sorting out the intrapersonal chaos caused by traumatic experiences is essential for healing, trauma is also a relational event that affects the individual survivor’s inner state and their web of close relationships (Kerig and Alexander, 2012, Matsakis, 2013). Positive family support is often central to the survivor’s recovery environment (Herman, 1997). Close relationships may provide the necessary support that can allow traumatized individuals to reconnect with themselves and others and engage in a healing process (Figley and Figley, 2009).

As Johnson (2002) asserts, ‘the nature of the recovery environment play[s] a part in determining the long-term effects of traumatic events’ (p. 26). In a review of studies of post-traumatic stress disorder (PTSD) Guay et al. (2006) conclude that the presence of social support is a key moderator in the development and treatment of post-trau- matic stress. However, it is not only the presence of social support that is important but also the quality of the recovery environment (Matsakis, 2013). Bracken et al. (1995) encourage clinicians to contex- tualize survivors’ experiences and consider the importance of the reconstruction of social, economic and cultural networks to facilitate healing and recovery. Negative interactions experienced in close rela- tionships increase the risk of developing or worsening PTSD.

In this article we summarize the most salient individual, group and relational evidence-based treatment approaches for trauma, and dis- cuss the importance of including family members in treatment. We also challenge the field of systemic interventions to provide more research and advocacy that will result in systemic interventions becoming a core consideration in treatment of trauma survivors and their partners and family members. We begin our discussion by

Relationships and families in healing from trauma 581

VC 2016 The Association for Family Therapy and Systemic Practice

providing an in-depth (although vivid) case study that illustrates the benefit of a systemic-oriented intervention.

Clinical case example

The following clinical example provides an illustration of trauma and differing outcomes, depending on whether a systemic or relational perspective is a part of treatment. This clinical case, based on real-life events, illustrates how the need for research and advocacy over sys- temic or relational trauma research is a top global public health issue. The case presents a graphic occurrence of trauma to which people all over the world are exposed, especially in countries ravaged by pov- erty, drug trafficking and war. As clinicians, it is important to consider that trauma is not an experience that happens only to the individual, but an event that influences every member of the family.

Alana Martin, aged 45, contacted a local mental health practitioner seek- ing counselling services after an extremely violent traumatic event. The Martin family lives in a small city in a Central American country ridden with violence and drug trafficking. James, aged 14, was kidnapped from his basketball practice one afternoon. Two men attacked and murdered his driver, a close family friend. James was taken away and held in a remote, secluded location. The kidnappers contacted his parents, Mike and Alana, a few hours later, asking for ransom money. Eddie, aged 10, James’ younger brother, was immediately removed from his home and sent to stay with an aunt in another city for his safety due to the possibility of subsequent kidnappings in these types of situations. Mike and Alana tried to reason with the kidnappers, asking them for enough time to attempt to gather the money for ransom. Their pleas were met with threats and increased pressure to deliver the money in its entirety soon. The couple pleaded for their son’s safety and promised to deliver the money as soon as possible. That night Mike and Alana had a huge marital argument after Mike blamed Alana for the kidnapping, claiming she had overlooked some common safety protocols. The next morning they received a small package with a piece of one of James’ toes. Alana and Mike both had severe panic attacks and were taken to the emergency room. Subsequently the Martins were able to secure the cash they needed and paid the ransom. James was returned to his family shortly after. Three months later, Alana is seeking counselling for her son James, wor- ried about his reintegration process after such a traumatic event. James has been reporting nightmares, flashbacks, trouble sleeping and difficul- ties in school. He has also refused to talk to his family about his experi- ence, saying that he would much rather just focus on the positives in life.

Gabriela López-Zerón and Adrian Blow582

VC 2016 The Association for Family Therapy and Systemic Practice

If Alana contacts a mental health practitioner who conceptualizes the experience of trauma and its subsequent treatment as an individ- ual process, the therapist might identify James as the client present- ing for treatment. The therapist might gravitate towards using an evidencebased approach centred on reducing the post-traumatic stress symptoms and the integration of the traumatic event into James’ narrative. Undoubtedly, based on the extensive body of work supporting exposure therapies for the treatment of trauma, James will experience relief and healing. His improvement might also indi- rectly positively impact on his family’s overall coping after such a trau- matic event. This kind of treatment would focus in the traumatic event itself and the related thoughts, emotions, and internal struc- tures related to the trauma.

On the other hand, if the mental health practitioner adopts a contextualized and relational treatment of trauma, the therapist might consider the entire Martin family as the client and involve Alana, Mike, and Eddie in treatment as well. Based on the discussion offered by this article, a relational approach to this traumatic event might integrate everyone’s experience, offer reconnection, and coach family members to adequately support James and each other. The traumatic event had a significant effect on everyone in the family, not only James. As it turns out, Eddie became afraid to venture out into the world. He grew more isolated and refused to take part in extramural activities at school. Alana incessantly blamed herself for what happened to James and began drinking more alcohol as a way to cope. In addition, marital arguments between Mike and Alana increased. The therapist’s effort to create a safe and affirming family environment is essential for a process of healing after such a violent traumatic event. This relational trauma treatment would address James’ symptoms individually to offer coping tools, while also guiding the family in their attempts to support each other and cope with the impact of trauma on each person and the fam- ily as a whole. The therapist would facilitate conversations to help the family talk together about the trauma for the first time. This would be a significant addition to the healing process for everyone, fostering safety and reconnection. These types of conversations are emotional, and require skill on the part of the therapist to keep all family members engaged and focused, while also helping them take a non-blaming stance. In addition, a skilled therapist with a systemic focus would also be able to address the marital and gender role issues manifesting in this family. An individually oriented approach for James would miss out on an opportunity for healing for everyone involved in the system.

Relationships and families in healing from trauma 583

VC 2016 The Association for Family Therapy and Systemic Practice

Trauma and its effects

Susan Johnson (2002) defines trauma as an event that occurs

‘when a person is confronted with a threat to the physical integrity of self or another, a threat that overwhelms coping resources and evokes subjective responses of intense terror, helplessness, and horror’. (p. 14)

Traumatic stress is viewed as a mind-body condition, linking physi- ological and emotional responses (Van der Kolk, 2000).

As the clinical case example above illustrates, traumatic experien- ces often involve interpersonal violence. Herman (1997) refers to these experiences as violations of human connection. Even if trau- matic experiences do not involve interpersonal violence, they often evoke reactions of fear, terror, and helplessness (Foy et al., 2001). These experiences tend to violate an individual’s assumption that the world is a safe place making it a challenge to hold the traumatic reality in consciousness (Herman, 1997). As a result, survivors often experi- ence a profound sense of alienation and disconnection (van der Kolk, 2003), impacting on their intrapersonal functioning and relation- ships. These emotions may cause survivors to feel isolated and ques- tion whether they are safe in the company of others or whether others are really available to support them (Foy et al., 2001; Matsakis, 2013). The disruption in interpersonal trust paired with the conse- quences of victimization, such as isolation and disconnection, can have a deep negative effect on the survivor’s overall quality of life. In order to hold a traumatic reality in consciousness and engage in a meaning-making process, an affirming and protective social context is necessary (Figley and Figley, 2009; Hawkins and Manne, 2013). For a survivor, that context is created through relationships with friends, family, partners, and the community (Herman, 1997; Walsh, 2007).

Significant advances in the study of psychological trauma have been made in the past few decades. PTSD is characterized by intru- sive re-experiencing symptoms, elevated arousal, and avoidance behaviours (American Psychiatric Association, 2013). With the grow- ing understanding of the biological aspects of PTSD, it has become clear that exposure to trauma can produce long-lasting effects in a survivor’s endocrine and nervous systems. Individuals with PTSD are more likely to experience gastrointestinal problems, asthma, and hypertension than those who do not have PTSD or elevated PTSD- type symptoms. PTSD can also become a chronic condition that is fre- quently comorbid with other mental health issues, such as depression,

Gabriela López-Zerón and Adrian Blow584

VC 2016 The Association for Family Therapy and Systemic Practice

anxiety, and substance abuse (McLean and Foa, 2011). Further, as illustrated in the case of the Martin family, trauma and PTSD does not affect only the individual who experienced it but it impacts on and disrupts the lives of all the members of a family system (Lebow and Rekart, 2013).

Given the pervasive nature of PTSD and the individual and societal impact of trauma exposure, there is a growing body of research and treatment protocols for the treatment of trauma. Several psychotherapy approaches with strong empirical evidence have been developed in the past several decades to help with trauma recovery. However, most of these protocols are individually focused and do not directly address sur- vivors’ interpersonal struggles or take into account their cultural back- grounds or context. Recently there have been efforts to address this issue. For instance, in the UK, the National Institute of Clinical Excel- lence recommended interpreting trauma protocols to ensure compe- tent and culturally appropriate services for survivors of diverse cultural backgrounds and dominant languages (d’ Ardenne et al., 2007). Fur- ther, there has been an increased recognition of the effects of trauma in survivors’ relationships and family functioning. In medical care in Vet- erans Affairs settings in the USA, couple and family therapists are slowly becoming a valued part of the treatment of PTSD (Figley and Figley, 2009).

Prominent individual therapy approaches

Although treating PTSD with pharmacology has accumulated sup- port, the Institute of Medicine considers trauma-focused cognitive behavioural therapy (TF-CBT) the first-level treatment for traumatic stress disorders (Institute of Medicine, 2008). The main goal in TF- CBT is for clients to face their traumatic memories instead of avoiding them, while also confronting thought patterns that reinforce the avoidance of traumatic memories. The three most studied and uti- lized trauma protocols are exposure therapy, cognitive processing therapy (CPT), and eye movement desensitization therapy (EMDR).

Exposure Therapy. Through repeated exposure to feared stimuli, expo- sure therapy promotes the extinction of the anxiety responses. Expo- sure therapy for the treatment of PTSD is based on the behavioural principle of fear acquisition. Treatment generally involves the repeated confrontation of the feared thoughts, objects, or situations

Relationships and families in healing from trauma 585

VC 2016 The Association for Family Therapy and Systemic Practice

in order to reduce problematic fear and anxiety responses, such as physical and emotional avoidance (Carr, 2005; McLean and Foa, 2011). Prolonged exposure (PE) is the most widely used exposure therapy protocol due to its strong empirical support for the reduction of PTSD intrapersonal symptoms. PE incorporates psychoeducation, imaginal and in vivo exposure to feared stimuli, and training in con- trolled breathing (McLean and Foa, 2011).

Neuner et al. (2004) developed narrative exposure therapy (NET), a variant of EP, to address PTSD symptoms in survivors of mass violence and torture. NET draws from EP’s basic techniques and adds a narra- tive component. The narrative element aims to contextualize trauma as part of the survivor’s experience (McPherson, 2012). NET places emphasis on the reconstruction of the trauma memory by incorporat- ing a detailed narration of the traumatic events (Adenauer et al., 2011). Several researchers have found evidence to support the use of NET for the treatment of PSTD among survivors of mass violence (Adenauer et al., 2011; Neuner et al., 2004).

CPT. While CPT is not as well-researched as Exposure Therapy, it has been shown to be effective in the treatment of PTSD symptoms (Bradley et al., 2005), particularly for combat veterans with chronic PTSD (Monson et al., 2012). CPT is similar to PE in its use of expo- sure and psychoeducation but adds a written narrative form of expo- sure to change the survivor’s maladaptive thoughts over the traumatic experience.

EMDR. EMDR is a CBT approach that involves exposure and cogni- tive processing with added simulation, usually in the form of saccadic eye movements (Solomon and Shapiro, 2008). The approach begins with the identification of symptoms that become triggered by trau- matic memories and focuses on reprocessing those traumatic events while also focusing on present triggers. Although there is some debate over the necessity of eye movements, EMDR treatment studies have found this protocol to be as effective as exposure therapy and CPT for the treatment of PTSD (Rogers and Silver, 2002).

The overall basic goals across individual trauma therapy approaches are twofold: firstly, they aim to restore affect regulation, specifically with feelings of fear and anger. Secondly, trauma therapy interventions aim to integrate the traumatic experiences into an empowered sense of self in order to engage in a meaning-making process (Figley and Figley, 2009; Johnson, 2002). Although these are

Gabriela López-Zerón and Adrian Blow586

VC 2016 The Association for Family Therapy and Systemic Practice

two crucial elements in the survivor’s healing process, it is difficult to actively address the role of the healing environment and the survi- vor’s ability to re-establish connections with others in the context of individual therapy. Not addressing the systemic or relational context in which a survivor exists has several risks. Most notably, the changes that occur to the survivor may cause stressful occurrences in their context. For example, a survivor may become more assertive because of effective treatment. This newfound assertiveness may then create conflict in relationships so they shift or change. Interventions that bridge this process are very helpful. Another risk is not providing the survivor with the necessary social support they need to sustain recov- ery from trauma. Having a supportive array of intimate, family, and community relationships provides the needed support for survivors to sustain a recovery process. To cope with their trauma survivors often turn to substance use and other types of self-harming behav- iour. These coping strategies can sabotage effective trauma recovery. The usefulness of a systemic approach is clear In the case of the Mar- tin family, as shown above. Changing the systemic relationship con- text in which a survivor lives is a critical component of sustained recovery (Guay et al., 2006; Johnson, 2002). It is thus clear that other systemic or relational modalities are necessary to address the complex interpersonal issues that may arise in the aftermath of trauma.

Group therapy approaches

Group therapy is a widely utilized treatment for trauma survivors, par- ticularly with child sexual abuse (CSA) survivors and adolescent survi- vors of trauma (Classen et al., 2001; Saltzman et al., 2013). However, relatively few randomized controlled trials have examined the efficacy of group psychotherapy for trauma specifically. The existing body of research does suggest that group therapy is effective in reducing depression, PTSD symptoms and dissociation, and improving interper- sonal skills and quality of life (Classen et al., 2001). Group therapies offer a safe space for the normalization of responses and processing of trauma among others who have similar experiences, giving survivors the opportunity to establish bonds and connections with others (Foy et al., 2001). Common across group intervention protocols is a clear emphasis on contextualizing symptoms and using the group environ- ment to decrease stigma and increase normalization and social support.

Relationships and families in healing from trauma 587

VC 2016 The Association for Family Therapy and Systemic Practice

Some studies report positive treatment effects for adults, children and adolescent survivors in group therapy protocols. However, there is no clear evidence of the superiority of any particular group theoretical approach or structure (Foy et al., 2001; Schnurr et al., 2003). While the case study example did not include group therapy as an intervention, it would have been useful for the individual in increasing support and in providing a safe place to process the traumatic experiences. From a systemic perspective, this approach on its own has limitations.

Couple and Family Therapy approaches

Trauma theorists agree that survivors need a safe place in order to stabilize the inner chaos caused by traumatic experiences and work on decreasing problematic trauma responses. Supportive environ- ments and people are indeed necessary to engage in this work; however, Johnson (2002) posits that in order to be resilient in the face of trauma, survivors do not only need a sense of community, they also need ‘close attachment bonds’ (p. 27). Monson et al. (2012) also say that intimate relationships can play an important role in recovery from post-traumatic stress and its comorbid intrapersonal and interpersonal impairments.

Henry et al.’s (2011) research finds that couple relationships are affected when there is a history of trauma in one or both partners. In their study, participants identified a wide range of issues that affected their relational functioning including boundary issues, intimacy prob- lems and confusion about roles in the relationship, among others. The researchers suggest that not addressing these symptoms in treat- ment may exacerbate both the individual and relational distress trauma survivors and their families may be experiencing. In the case of the Martin family, the traumatic event directly happened to the cou- ple’s son; however, the event was so extreme, that it severely impacted on the couple’s relationship as well as on individual functioning. Not addressing how such a violent event affects the couple relationship may exacerbate individual and relational distress.

Although there is a dearth of literature exploring relational trauma interventions, some treatment protocols have demonstrated it has positive results, for instance, in the use of CBT for couples in which one of the partners is a combat veteran diagnosed with PTSD (Mon- son et al., 2012). The CBT protocol for couples included psychoedu- cation about the ‘reciprocal influences of PTSD symptoms and

Gabriela López-Zerón and Adrian Blow588

VC 2016 The Association for Family Therapy and Systemic Practice

relationship functioning’ (p. 702), strategies to create a shared sense of safety, and problem solving and decision-making skills. Research- ers found that this protocol ameliorated PTSD symptoms as well as relationship satisfaction.

Emotionally Focused Therapy (EFT) is an attachment-based cou- ple therapy that emphasizes the role of affect and emotion in thera- peutic change (Johnson, 2002). Trauma survivors often experience difficulty re-establishing connections, and research indicates that con- nection and safety are critical in trauma healing (Herman, 1997). There is some empirical support for EFT’s treatment of general cou- ple distress and Johnson (2002) asserts that EFT’s attention to estab- lishing and maintaining a safe and secure attachment bond between partners is vital in creating a healing environment in the aftermath of trauma.

A recent study examined the effectiveness of EFT in couples where one of the partners was a survivor of CSA (Dalton et al., 2013). The study’s findings suggest that the link between childhood trauma and marital outcomes could be mediated by the ability to form secure attachments with others (Whisman, 2006). Participants in Dalton et al.’s (2013) study demonstrated an increase in relationship satisfac- tion over time and an improvement in marital functioning. The results suggest that EFT offers a viable option for helping clients reconnect with significant others and further their progress in recov- ery and healing.

Kerig and Alexander (2012) propose the integration of trauma com- ponents to Functional Family Therapy (FFT), an evidence-based model, in the treatment of traumatized youth involved in the juvenile justice system. The authors indicate it is importance to address the effects of these traumatic experiences in the context of the family sys- tem. Families can foster sources of resilience such as connectedness, affection, and bonding, essential for trauma healing. Trauma-focused FFT frames the traumatic experience in relational terms that recognize that all family members are affected by trauma, even if only one mem- ber directly experienced the traumatic event.

Multi-family group interventions based on behavioural and skill- building components have strong empirical support in enhancing family functioning and connection (McFarlane et al., 2004). Although there are limited empirically supported interventions for distressed families exposed to trauma or living in traumatic con- texts, Kiser et al. (2010) proposed a multi-family group intervention that builds on families’ resources to enhance the coping mechanisms

Relationships and families in healing from trauma 589

VC 2016 The Association for Family Therapy and Systemic Practice

and protective factors that may mediate the effects of trauma expo- sure. This trauma-focused intervention based in empirically sup- ported treatment components has positive effects on post-traumatic symptoms.

The approaches described all include family or relationships as a part of the treatment for trauma survivors. Their broad goals are to increase positive support and connection among family members, create safety, and reduce negative interactional cycles. These approaches have a growing body of evidence showing their in reduc- ing the effects of trauma symptoms in survivors in some cases. As in the case of the Martin family, a traumatic event, may even have severe repercussions on other members of the family. A treatment approach that attends to the needs of all family members while fostering a sup- portive and safe environment is essential to reconnection and healing.

Unique elements among relational trauma interventions

We reviewed systemic treatments with an eye on their commonalities in strategies and change mechanisms. Families often avoid discussing trauma, leaving survivors and family members feeling isolated and disconnected from vital sources of support (Coulter, 2013). Although there are a limited number of relational interventions for trauma, the existing protocols contain two unique elements that are rarely addressed through individually focused therapy alone, primarily because the latter attend mostly to the intrapersonal impact of trauma.

The first core element of relational interventions for trauma is the psychoeducational component aimed at enhancing each family mem- ber’s understanding of how trauma affects individual and family func- tioning (Coulter, 2013; Kerig and Alexander, 2012; Monson et al., 2012). This education serves to normalize the experiences of family members and to address issues of communication over symptoms and coping. Further, those conversations can provide an opportunity for members to co-create the meaning of the experience, facilitating heal- ing (Coulter, 2013). A contextualized and relational approach to treat- ing the Martin family would provide opportunities for the family to talk about how the trauma affected each individual in the family, nor- malizing individual responses while fostering reconnection. Psycho- education offered in the context of a relational treatment provides a

Gabriela López-Zerón and Adrian Blow590

VC 2016 The Association for Family Therapy and Systemic Practice

way to increase a sense of competency and normalcy, improve coping strategies, and increase support among family members (Rabin and Apel, 2013).

Closely related is the second significant element in relational approaches for trauma: attention to a process of reconnection and bonding within the system. Catherall (1999) discusses the impor- tance of facilitating the family’s support of the traumatized member by helping the entire system to function as a team in dealing with the aftermath of trauma. The interaction between the individuals who directly experience trauma and the rest of the family is recip- rocal in nature (Coulter, 2013), suggesting a strong potential for the family to affect the course of recovery. This reconnection process would support the Martin family and others like it, not only by increasing the positive social bonds in the family but also by allow- ing the family to grow in step with the survivor, who invariably experiences significant life changes because of effective trauma treatment.

Post-traumatic growth (PTG)

An important part of expanding our understanding of trauma and its aftermath is recognizing that survivors often report experiences of positive change in their struggles with adversity. In the last few deca- des, the trauma literature has used different terminologies to describe this phenomenon, such as PTG (Tedeschi and Calhoun, 1996) and adversity-activated development (Papadopoulos, 2007). Tedeschi and Calhoun (1996) describe PTG as ‘positive psychological change expe- rienced as a result of the struggle with highly challenging life circum- stances or traumatic events’ (p. 1). As a result of PTG, individuals often report a greater appreciation for life, changes in life philosophy, changes in their self-view, including a greater sense of personal strength, and an enhancement in their personal relationships. Papa- dopoulos (2007) proposed a ‘trauma grid’ to identify the various con- sequences of traumatic experiences at the individual, family, community and societal levels in order to address the effects of trauma more appropriately by avoiding oversimplification and polarization.

These potential experiences of positive change and growth have a profound impact on survivor’s close relationships. Thus, the inclusion these relationships in treating trauma seems profoundly relevant

Relationships and families in healing from trauma 591

VC 2016 The Association for Family Therapy and Systemic Practice

when considering the influence of the individual’s environment in their recovery, healing and growth processes. As an individual grows, relationships change and grow as well. Following a traumatic event, particularly one that involves violence, as in the case of the Martin family, safety within relationships needs to be restored as a part of the recovery process. Fostering tolerance within families of the survivor’s erratic fluctuations from instances of closeness to moments of distance during the recovery process is critical for successful recovery. It is within the safety of relationships and close connections that survivors are able to reintegrate the trauma information into a cohesive narra- tive, leading to growth and healing.

Most of the research on PTG has focused exclusively on individual experiences, without paying much attention to the impact of their social supports (Büchi et al., 2009). However, in a study of couples coping with cancer, Kunzler et al. (2014) found that support from an intimate partner plays a critical role in a patient’s adjustment. The study shows that couples not only share the burden of a cancer diag- nosis, they may also share the potentially positive benefits. These findings suggest that the influence of a couple’s joint benefit and growth experience may be a powerful force in recovery and adjust- ment. Büchi et al. (2009)’s study on grief processes in couples after the death of their premature baby shows that the emotional exchange between partners after their loss may be vital for a process of shared and concordant grief. The results of the study suggest that in con- cordant grief processes both partners also share a process of growth.

A systemic approach to understanding the negative, positive and neutral psychological effects of trauma is vital to explore whether PTG is not only an individual experience, but can also be a relational occurrence. More research is needed to understand the complexity of this phenomenon, including the interactive effects on individual and relational PTG.

Challenge to the field of systemic or relational therapies

Trauma survivors often experience a sense of betrayal and distrust in the wake of traumatic events. It is, therefore, appropriate to concep- tualize trauma as a family event, something that affects the individual who directly experiences the traumatic event and their most intimate relationships in social and cultural contexts. Further, as Bracken (2001) asserts, if contextual issues are central in determining how

Gabriela López-Zerón and Adrian Blow592

VC 2016 The Association for Family Therapy and Systemic Practice

trauma is experienced, developing supportive environments condu- cive to healing and reconnection is essential. Although individualized approaches that address problematic traumatic stress symptoms are necessary, wider systemic approaches that incorporate the possibility of experiencing individual and relational growth following the trau- matic event and that emphasize the individual’s environment and relationships are fundamental for healing.

Noted trauma experts such as Herman (1997), Bracken et al. (1995), Bracken (2001) and Johnson (2002), suggest that connection with others is at the heart of trauma healing. Recovering from trauma involves helping the survivor reorganize their intrapsychic world through the creation of new safe and affirming interpersonal connec- tions. However, there is limited empirical support for trauma-focused group approaches. Similarly, there are few studies that explore couple therapy and family therapy trauma-focused modalities, even though the initial evidence is very promising. Emotional attachment is consid- ered as one of the primary protection mechanisms against feelings of hopelessness and meaninglessness (McFarlane and Van der Kolk, 1996). It therefore seems clear that improving individuals’ closest rela- tionships and understanding how those relationships can be a source of strength and healing can be a crucial element in addressing the problems that affect trauma survivors’ physical and mental health.

When discussing the effects of trauma, theorists, clinicians, and researchers all agree that the presence of post-traumatic stress primar- ily affects the individual’s ability to process traumatic experiences (Boss, 2006; Herman, 1997; Van der Kolk, 2000). As noted earlier, this individual process affects and is affected by relationships. However, barriers remain for relational or systemic-oriented treatments to become fully integrated into widely used trauma-focused treatment protocols. This is because, even though there is research pointing to the initial efficacy of these interventions as a core and adjunctive treat- ment, not enough efforts have been made to increase the scope of this research or to prioritize its importance globally. In addition, there is a need for increased advocacy efforts to publicize these interventions worldwide as core healing strategies. There is a need for further research to expand our understanding of how trauma manifested within couple and family relationships and how treatment interven- tions can address these challenges in a strength-based, supportive envi- ronment that facilitates healing. Further, McLean and Foa (2011) found that most therapists do not use evidence-based treatments for PTSD due to a lack of training. These findings call for the better

Relationships and families in healing from trauma 593

VC 2016 The Association for Family Therapy and Systemic Practice

dissemination of protocols, particularly for clinicians working with trauma in the context of couple or family therapy.

References

Adenauer, H., Catani, C., Gola, H., Keil, J., Ruf, M., Schauer, M. et al. (2011) Nar- rative exposure therapy for PTSD increases top-down processing of aversive stimuli - evidence from a randomized controlled treatment trial. BMC Neuro- science, 12: 127. doi: 10.1186/1471-2202-12-127

American Psychiatric Association (2013) Diagnostic and statistical manual of mental disorders (5th edn). Washington, DC: author.

Boss, P. (2006) Loss, trauma, and resilience: therapeutic work with ambiguous loss. New York, NY: WW Norton ’ Co.

Bracken, P. J. (2001) Post-modernity and post-traumatic stress disorder. Social Sci- ence ’ Medicine, 53(6): 733–743. doi:10.1016/S0277-9536(00)00385-3

Bracken, P. J., Giller, J. E. and Summerfield, D. (1995). Psychological responses to war and atrocity: the limitations of current concepts. Social Science ’ Medicine, 40(8): 1073–1082. doi:10.1016/0277-9536(94)00181-R

Bradley, R., Greene, J., Russ, E., Dutra, L. and Westen, D. (2005) A multidimen- sional meta-analysis of psychotherapy for PTSD. American Journal of Psychiatry, 162(2): 214–227.

Breslau, N. (2009) The epidemiology of trauma, PTSD, and other posttrauma disorders. Trauma, Violence, and Abuse: A Review Journal, 10(3): 198–210. doi: 10.1177/1524838009334448

Büchi, S., Mörgeli, H., Schnyder, U., Jenewein, J., Glaser, A., Fauchère, J. C., et al. (2009) Shared or discordant grief in couples 2–6 years after the death of their premature baby: effects on suffering and posttraumatic growth. Psychoso- matics, 50(2): 123–130.

Carr, A. (2005) Contributions to the study of violence and trauma multisystemic therapy, exposure therapy, attachment styles, and therapy process research. Journal of Interpersonal Violence, 20(4), 426–435. doi:10.1177/0886260504267883

Catherall, D.R. (1999) Family as a group treatment for PTSD. In B.H. Young and D.D. Blake (eds) Group treatments for post-traumatic stress (pp.15–34). Philadel- phia, PA: Brunner and Mazel.

Classen, C., Koopman, C., Nevillmanning, K. and Spiegel, D. (2001) A prelimi- nary report comparing trauma-focused and present-focused group therapy against a Wait-listed condition among childhood sexual abuse survivors with PTSD. Journal of Aggression, Maltreatment ’ Trauma, 4(2): 265–288. doi: 10.1300/J146v04n02_12

Coulter, S. (2013) Systemic psychotherapy as an intervention for post-traumatic stress responses: an introduction, theoretical rationale and overview of develop- ments in an emerging field of interest. Journal of Family Therapy, 35: 381–406.

Dalton, E. J., Greenman, P. S., Classen, C. C. and Johnson, S. M. (2013) Nurtur- ing connections in the aftermath of childhood trauma: a randomized controlled trial of emotionally focused couple therapy for female survivors of childhood abuse. Couple and Family Psychology: Research and Practice, 2(3): 209–221. doi: 10.1037/a0032772

Gabriela López-Zerón and Adrian Blow594

VC 2016 The Association for Family Therapy and Systemic Practice

D’ Ardenne, P., Farmer, E., Ruaro, L. and Priebe, S. (2007) Not lost in translation: protocols for interpreting trauma-focused CBT. Behavioural and Cognitive Psychotherapy, 35(03): 303–316. doi:10.1017/S1352465807003591

Figley, C. R. and Figley, K. R. (2009) Stemming the tide of trauma systemically: the role of family therapy. Australian and New Zealand Journal of Family Therapy, 30(3): 173–183.

Foy, D. W., Eriksson, C. B. and Trice, G. A. (2001) Introduction to group inter- ventions for trauma survivors. Group Dynamics: Theory, Research, and Practice, 5 (4): 246–251. doi:10.1037/1089-2699.5.4.246

Guay, S., Billette, V. and Marchand, A. (2006) Exploring the links between post- traumatic stress disorder and social support: processes and potential research avenues. Journal of Traumatic Stress, 19(3): 327–338. doi: 10.1002/jts.20124

Hawkins, S.S. and Manne, S.L. (2013) Family support in the aftermath of trauma. In D.R. Catherall (ed.) Handbook of stress, trauma and the family (pp. 231–260). Abingdon, Oxon: Routledge.

Henry, S. B., Smith, D. B., Archuleta, K. L., Sanders Hahs, E., Goff, B. S. N., Reisbig, A. M., Schwerdtfeger, K. L., Bole, A., Hayes, E., Hoheisel, C.B., Nye, B., Osby-Williams, J. and Herman, J. L. (1997) Trauma and recovery. New York, NY: Basic Books.

Herman, J. L. (1997) Trauma and Recovery. New York: Basic Books. Institute of Medicine (2008) Treatment of posttraumatic stress disorder: an assessment of

the evidence. [Data file]. Retrieved from http://www.pdhealth.mil/downloads/ TreatmentofPosttraumaticStressDisorder(IOM2007).pdf

Johnson, S. M. (2002) Emotionally focused couple therapy with trauma survivors: strengthening attachment bonds. New York, NY: Guilford Press.

Kerig, P. K. and Alexander, J. F. (2012) Family matters: integrating trauma treat- ment into functional family therapy for traumatized delinquent youth. Journal of Child and Adolescent Trauma, 5(3): 205–223. doi: 10.1080/19361521.2012.697103

Kiser, L. J., Donohue, A., Hodgkinson, S., Medoff, D. and Black, M. M. (2010) Strengthening family coping resources: the feasibility of a multifamily group intervention for families exposed to trauma. Journal of Traumatic Stress, 23(6): 802–806. doi: 10.1002/jts.20587

Künzler, A., Nussbeck, F. W., Moser, M. T., Bodenmann, G. and Kayser, K. (2014) Individual and dyadic development of personal growth in couples coping with cancer. Supportive Care in Cancer, 22(1): 53–62.

Lebow, J. and Rekart, K.N. (2013) Research assessing couple and family thera- pies for posttraumatic stress disorder. In D.R. Catherall (ed.) Handbook of stress, trauma and the family (pp. 261–279). Abingdon, Oxon: Routledge.

Matsakis, A. (2013)Trauma and its impact on families. In D.R. Catherall (ed.) Hand- book of stress, trauma and the family (pp. 15–32). Abingdon, Oxon: Routledge.

McFarlane, A. C. and van der Kolk, B. A. (1996) Trauma and its challenge to soci- ety. In B. A. van der Kolk, A. C. McFarlane and L. Weisaeth (eds), Traumatic Stress: the Effects of Overwhelming Experience on Mind, Body, and Society (pp. 24– 46). New York: Guilford.

McFarlane, W. R., Lefley, H. P. and Beels, C. C. (2004) Multifamily groups in the treatment of severe psychiatric disorders. New York: Guilford.

McLean, C. P. and Foa, E. B. (2011) Prolonged exposure therapy for post- traumatic stress disorder: a review of evidence and dissemination. Expert Review of Neurotherapeutics, 11(8): 1151–63. doi: 10.1586/ern.11.94

Relationships and families in healing from trauma 595

VC 2016 The Association for Family Therapy and Systemic Practice

McPherson, J. (2012) Does narrative exposure therapy reduce PTSD in survivors of mass violence? Research on Social Work Practice, 22(1): 29–42. doi:10.1177/ 1049731511414147

Monson C.M., Fredman S.J., Macdonald A., Pukay-Martin N.D., Resick P.A. and Schnurr P.P. (2012) Effect of cognitive-behavioral couple therapy for PTSD: a randomized controlled trial. JAMA, 308(7): 700–709. doi:10.1001/jama.2012. 9307

Neuner, F., Schauer, M., Klaschik, C., Karunakara, U. and Elbert, T. (2004) A comparison of narrative exposure therapy, supportive counseling, and psy- choeducation for treating posttraumatic stress disorder in an African refugee settlement. Journal of Consulting and Clinical Psychology, 72(4): 579–587. doi: 10.1037/0022-006X.72.4.579

Papadopoulos, R. K. (2007) Refugees, trauma and adversity-activated develop- ment. European Journal of Psychotherapy and Counselling, 9: 301–312.

Rabin, C. and Apel, Z. (2013) Psychoeducational treatment of stressed and trau- matized couples. In D.R. Catherall (ed.) Handbook of stress, trauma and the family (pp. 453–471). Abingdon, Oxon: Routledge.

Regehr, C. and Sussman, T. (2004) Intersections between grief and trauma: toward an empirically based model for treating traumatic grief. Brief Treatment and Crisis Intervention, 4(3): 289–309. doi: 10.1093/brief-treatment/mhh025

Rogers, S. and Silver, S. M. (2002) Is EMDR an exposure therapy? A review of trauma protocols. Journal of Clinical Psychology, 58(1): 43–59. doi: 10.1002/ jclp.1128

Rycroft, P. and Perlesz, A. (2001) Speaking the unspeakable: reclaiming grief and loss in family life. The Australian and New Zealand Journal of Family Therapy, 22 (2), 57–65.

Saltzman, W.R., Babayan, T., Lester, P., Beardslee, W.R. and Pynoos, R.S. (2009) Family-based treatment for child traumatic stress. In D. Brom, R. Pat-Horenc- zyk and J. Ford (eds.) Treating traumatized children: risk, resilience and recovery (pp. 240–254). New York: Routledge.

Saltzman, W. R., Pynoos, R. S., Lester, P., Layne, C. M. and Beardslee, W. R. (2013) Enhancing family resilience through family narrative co-construction. Clinical Child and Family Psychology Review, 16(3): 294–310. doi: 10.1007/ s10567-013-0142-2

Sandler, I. N., Wolchik, S. A. and Ayers, T. S. (2007) Resilience rather than recov- ery: a contextual framework on adaptation following bereavement. Death Studies, 32(1): 59–73. doi:10.1080/07481180701741343

Schnurr, P.P., Friedman, M.J., Foy, D.W., Shea, T., Hsieh, F.Y., Lavori, P.W., Glynn, S.M., Wattenberg, M. and Bernardy, N. (2003) Randomized trial of trauma-focused group therapy for posttraumatic stress disorder: results from a department of veterans affairs cooperative study. Archives of General Psychiatry, 60 (5): 481–489. doi:10.1001/archpsyc.60.5.481

Solomon, R. M. and Shapiro, F. (2008) EMDR and the adaptive information processing model: potential mechanisms of change. Journal of EMDR Practice and Research, 2(4): 315–325. doi:10.1891/1933-3196.2.4.315

Tedeschi, R. G. and Calhoun, L. G. (1996) The posttraumatic growth inventory: measuring the positive legacy of trauma. Journal of Traumatic Stress, 9(3): 455–471. doi:10.1007/BF02103658

Gabriela López-Zerón and Adrian Blow596

VC 2016 The Association for Family Therapy and Systemic Practice

Van der Kolk, B. A. (2003) The neurobiology of childhood trauma and abuse. Child and Adolescent Psychiatric Clinics of North America, 12(2): 293–317. doi: 10.1016/S1056-4993(03)00003-8

Van der Kolk, B. A. (2000) Posttraumatic stress disorder and the nature of trauma. Dialogues in Clinical Neuroscience, 2(1): 7–22.

Walsh, F. (2007) Traumatic loss and major disasters: strengthening family and community resilience. Family Process, 46: 207–227.

Whisman, M. A. (2006) Childhood trauma and marital outcomes in adulthood. Personal Relationships, 13(4): 375–386. doi:10.1111/j.1475-6811.2006.00124.x

Relationships and families in healing from trauma 597

VC 2016 The Association for Family Therapy and Systemic Practice

Copyright of Journal of Family Therapy is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.