How family members express psychological distress & resources in war trauma? Raija-Leena Punamäki, University of Tampere, Finland & Samir Qouta & Eyad

How family members How family members express psychological express psychological distress & resources in distress & resources in

war trauma?war trauma?Raija-Leena Punamäki, University of Raija-Leena Punamäki, University of

Tampere, FinlandTampere, Finland&&

Samir Qouta & Eyad El Sarraj, Gaza Community Mental Health Program, Gaza,

Palestine

© Raija-Leena Punamäki 2007

How family members How family members express psychological express psychological distress & resources in distress & resources in

war trauma?war trauma?Raija-Leena Punamäki, University of Raija-Leena Punamäki, University of

Tampere, FinlandTampere, Finland&&

Samir Qouta & Eyad El Sarraj, Gaza Community Mental Health Program, Gaza,

Palestine


Study IStudy I

Impact on trauma on family Impact on trauma on family members’ psychological distress members’ psychological distress & resources & resources


Family approach to war & Family approach to war & military violencemilitary violence

Family system provides Family system provides the parents & siblings the parents & siblings distinct roles & tasksdistinct roles & tasks

Emotional, cognitive & Emotional, cognitive & behavioral ‘share of work’ behavioral ‘share of work’

Serves family’s survival, Serves family’s survival, adaptation & balance adaptation & balance


Impact of trauma on familiesImpact of trauma on families

Family roles crystallize in the Family roles crystallize in the face of threat, danger & traumaface of threat, danger & trauma

If flexible & short-living, strict If flexible & short-living, strict roles enhance effective coping & roles enhance effective coping & learning learning

If ‘cemented’ & permanent, they If ‘cemented’ & permanent, they prevent child development & prevent child development & can form risks for mental health can form risks for mental health problems problems


Research hypothesesResearch hypotheses Exposure to military trauma Exposure to military trauma

differently impactsdifferently impacts family family members’ mental health and members’ mental health and resiliency responses resiliency responses

Siblings & parents may show Siblings & parents may show compensatorycompensatory and/or and/or symmetricsymmetric vulnerability & vulnerability & resiliencyresiliency


Participants: Palestinian Participants: Palestinian families in Gazafamilies in Gaza

65 quintets of three siblings, 65 quintets of three siblings, mother & father mother & father

Siblings 13-, 15- & 18-year-olds Siblings 13-, 15- & 18-year-olds Follow-up sample from the Follow-up sample from the

Intifada I: 108 target children, Intifada I: 108 target children, then 8-year-oldsthen 8-year-olds

Boys 48%, girls 52%Boys 48%, girls 52% 70% from refugee camps, 20% 70% from refugee camps, 20%

town, and 10% resettled areas town, and 10% resettled areas



MeasuresMeasures Traumatic eventsTraumatic events: (a) Military-related : (a) Military-related

10 items, e.g. loss of family members 10 items, e.g. loss of family members as dead & detained, being wounded & as dead & detained, being wounded & destruction & violence (b)Family-destruction & violence (b)Family-related: report of personal trauma: related: report of personal trauma: illness, human conflicts illness, human conflicts

Mental health problemsMental health problems: PTSD, : PTSD, depression & neuroticism depression & neuroticism

Resiliency responsesResiliency responses: Quality of life : Quality of life (satisfaction, vitality, fulfillment), (satisfaction, vitality, fulfillment), resiliency (creativity, persistency, resiliency (creativity, persistency, relationships) & self-esteemrelationships) & self-esteem


Result 1: Result 1: Trauma-related differences between Trauma-related differences between family members found in PTSDfamily members found in PTSD

PTSD among Family Members

according to Trauma

Family Members

MotherFatherChild 18Child 13Child 15

Total Score

34

32

30

28

26

24

22

Level of trauma

Low

High


Result 2. Result 2. Trauma increases depressive symptoms in Trauma increases depressive symptoms in all, no family-member differencesall, no family-member differences

Depression among Family Members

according to Trauma

Family Members

MotherFatherChild 18 yearsChild 13 yearsChild 15 years

Total Scores

7

6

5

4

3

2

Level of Trauma

Low

High


Result 4: Result 4: High trauma associates with low quality of High trauma associates with low quality of life only among fatherslife only among fathers

Quality of Life among Family

Members according to Trauma

Family Members


Total Score

120

110

100

90

Level of Trauma

Low

High


Result 5: Result 5: Only family membership, not trauma, Only family membership, not trauma, determines the level of resiliencydetermines the level of resiliency

Resiliency among Family Members

according to the Level of Trauma

Family Members


Means

3,8

3,7

3,6

3,5

3,4

3,3

3,2

Level of Trauma

Low

High


Result 6:Result 6:High trauma associates with low self-High trauma associates with low self-esteem among all siblingsesteem among all siblings

Self-esteem among Siblings

according to Trauma

Siblings

Child 18 yearsChild 13 yearsChild 15 years

Total score

67

66

65

64

63

62

6160

Level of Trauma

Low

High


Figure 6.Figure 6. Family Type and Traumatic Family Type and Traumatic EventsEvents

2,5

3

3,5

4

4,5

5

Ordeal FamilyResilient FamilyParental StrenghtChildren's strenght

Military Trauma

Personal Trauma


ConclusionsConclusions

Compensatory dynamics: Parents: fathers Compensatory dynamics: Parents: fathers resist PTSD, but vulnerable in quality of resist PTSD, but vulnerable in quality of life; mothers resilient if husband life; mothers resilient if husband vulnerable vulnerable

Younger children ‘carry’ PTSD (intrusion, Younger children ‘carry’ PTSD (intrusion, avoidance & hyper arousal) avoidance & hyper arousal)

Typology showed clear generational Typology showed clear generational boundaries: resiliency (e.g. persistency & boundaries: resiliency (e.g. persistency & support) in either parents or siblings: support) in either parents or siblings:

Tailored interventions for families & Tailored interventions for families & members members


Study IIStudy II

Mother-child distress in extreme Mother-child distress in extreme trauma: destruction of home trauma: destruction of home


Research task:Research task:

Two alternatives how exposure to trauma Two alternatives how exposure to trauma impacts mothers and their children’s impacts mothers and their children’s distressdistress

Accumulation and dose-effect: both suffer Accumulation and dose-effect: both suffer when trauma severity increaseswhen trauma severity increases

Family systems approach: (a) ’share of Family systems approach: (a) ’share of work’ in distress expression (b) work’ in distress expression (b) reciprocical worry (c) contamination & reciprocical worry (c) contamination & specifity of symptom expressionspecifity of symptom expression


Participants: Mothers & their 6-16-Participants: Mothers & their 6-16-year-old children in Gazayear-old children in Gaza

121 families in destroyed areas 121 families in destroyed areas during the Al Aqsa Intifada during the Al Aqsa Intifada

Part of an intervention study Part of an intervention study Mothers & their 6-16-year-old Mothers & their 6-16-year-old

children children Boys 54.6%, girls 45.4%Boys 54.6%, girls 45.4%



MeasuresMeasures

Trauma exposure Trauma exposure 12 events including witnessing & being 12 events including witnessing & being

the target (e.g. saw family member the target (e.g. saw family member killed, shelling of home, being shot at)killed, shelling of home, being shot at)

Mothers and children separately Mothers and children separately reportedreported

Mental healthMental health PTSD (Mothers: Allodi DSM ; PTSD (Mothers: Allodi DSM ; Children: Pynoos CPTS-Ri) Children: Pynoos CPTS-Ri) Psychological distress (Mothers: Psychological distress (Mothers:

SCL_90, SCL_90, Children: Rutter: RA2) Children: Rutter: RA2)


Results Results

Family systems model was Family systems model was substantiated in girlssubstantiated in girls

Accumulation model was substantiated Accumulation model was substantiated in boysin boys Dyadic symptom expression specificity: Dyadic symptom expression specificity: Mother hostile – child externalizing symptoms Mother hostile – child externalizing symptoms Mother depressive – child internalizing symp.Mother depressive – child internalizing symp. Not PTSD specificity found Not PTSD specificity found


Family War Trauma and Children’s PTSD-symptoms Family War Trauma and Children’s PTSD-symptoms

among Boys and Girlsamong Boys and Girls

3032343638404244464850

PTSD

Both LowMother High Child High Both High

Family War Trauma

Boy

Girl


Maternal Depressive & Anxiety Symptoms according to Maternal Depressive & Anxiety Symptoms according to Family War TraumaFamily War Trauma

131517192123252729

Symptoms

Both LowMother HighChild HighBoth High

Family War Trauma

DepressiveAnxiety


Importance of AttachmentImportance of Attachment (J. Bowlby, M. Ainsworth, M. Main, P. Crittenden)(J. Bowlby, M. Ainsworth, M. Main, P. Crittenden)

Child attachment behavior is Child attachment behavior is precondition for survival precondition for survival

Early working models of thrust, own Early working models of thrust, own worth, safety & benevolence of the worth, safety & benevolence of the world and others world and others

In adulthood danger and trauma In adulthood danger and trauma activate activate attachment/working modelsattachment/working models

CCrystallizerystallize responses typical to each responses typical to each attachment styleattachment style


Study IIIStudy III Adult Attachment & Cognitive-Adult Attachment & Cognitive-Emotional Processing of trauma Emotional Processing of trauma


” ” Fatherhood of a national hero”Fatherhood of a national hero”

Oslo agreement (Israel & PLO, 1993): Oslo agreement (Israel & PLO, 1993): 8 000 political prisoners released8 000 political prisoners released

Motivation for seeking psychological help: Motivation for seeking psychological help: * anger & intrusive memories harm intimate* anger & intrusive memories harm intimate relationship relationship * feeling failure in being a father: outsider * feeling failure in being a father: outsider * numbing of feelings* numbing of feelings (not so much for PTSD)(not so much for PTSD)

The ’big question’ how to process trauma-related The ’big question’ how to process trauma-related emotionsemotions


Adult Attachment & emotionsAdult Attachment & emotionsSecure-balancedSecure-balanced Access to both negative & positive feelingsAccess to both negative & positive feelings Access to both emotions & cognitionAccess to both emotions & cognitionInsecure-dismissingInsecure-dismissing Distrust emotions; minimizes feelingsDistrust emotions; minimizes feelings Emphasis on analytic & cognitive modeEmphasis on analytic & cognitive modeInsecure-preoccupiedInsecure-preoccupied Distrust cognitions, ignores informationDistrust cognitions, ignores information Emotions overwhelmingEmotions overwhelming


Multilevel Model of Emotions Multilevel Model of Emotions (N.Fridja)(N.Fridja)

a) Domains of emotionsa) Domains of emotions Behavioral: action readinessBehavioral: action readiness Cognitive: appraisal & metacognitionsCognitive: appraisal & metacognitions Affective: feelings, mood Affective: feelings, mood Physiological level: arousalPhysiological level: arousalb) Intensity and valence of emotionsb) Intensity and valence of emotionsc) Content & autobiographical meaningc) Content & autobiographical meaning


Study HypothesesStudy Hypotheses::

Emotional processing of trauma is Emotional processing of trauma is biased among insecurely biased among insecurely attached individuals:attached individuals:

Dismissing use predominantly Dismissing use predominantly cognitive modescognitive modes

Preoccupied use predominantly Preoccupied use predominantly emotional feeling statesemotional feeling states


Secure individuals use Secure individuals use balanced emotional-cognitive balanced emotional-cognitive processingprocessing

Exposure to trauma activates Exposure to trauma activates the attachment-specific the attachment-specific emotional processingemotional processing


ParticipantsParticipants 153 Palestinian 153 Palestinian

men, Gazamen, Gaza Political Political

prisonersprisoners Released accord. Released accord.

Oslo agreement Oslo agreement 19-50 year-olds 19-50 year-olds

(29.4(29.4++5.7)5.7) Education: 33% Education: 33%

university 37%, university 37%, secondary, 7% secondary, 7% primary schoolprimary school

Local clinicsLocal clinics




The Association between Trauma Exposure & The Association between Trauma Exposure & Posttraumatic Growth according Posttraumatic Growth according

to Attachment Security to Attachment Security

Low Trauma High Trauma

Low SecureHigh Secure

3.8

3.6

3.4

3.2


. .

Low Trauma High Trauma

Low AvoidanceHigh Avoidance

1.8

1.4

1

0.6

0.2

The Association between Trauma & The Association between Trauma & Negative Emotions according Negative Emotions according

to Avoidant Attachment to Avoidant Attachment


Implications for trauma reseach Implications for trauma reseach

Multilevel analysis: Multilevel analysis: Individual underlyingIndividual underlying mechanisms: cognitive, emotional, mechanisms: cognitive, emotional, psychophysiological and hormonal psychophysiological and hormonal FamilyFamily: Parental, sibling and transgenerational : Parental, sibling and transgenerational subsystems, shared-nonshared environmentssubsystems, shared-nonshared environments CultureCulture: which processes are universal vs. culture-: which processes are universal vs. culture-related vs. both: cognitive, emotional, social, related vs. both: cognitive, emotional, social, biological biological Reconsideration of Poortinga modelReconsideration of Poortinga model Developmental approach: Developmental approach: infant psychology; new infant psychology; new understanding of adolescence; new look at ’critical understanding of adolescence; new look at ’critical periods’; brain development and modulationperiods’; brain development and modulationFamily systems theory & Evolution psychology:Family systems theory & Evolution psychology: Integration of attachment and trauma theory:Integration of attachment and trauma theory:


Before therapy During therapy After therapy

PERSONALITY •Adult attachment

•Defence styles

THERAPY PROCESS •Alliance

•Significant events

•Feeling states

EMOTIONAL-COGNITIVE

PROCESSING

•Self- and object representations



•Emotional responses

•Dreaming •Emotional responses

MENTAL HEALTH •PTSD •PTSD •PTSD

•Somatic symptoms

•Somatic symptoms

•Soma tic symptoms

•Personal growth •Personal growth •Personal growth

Reseach Setting and Procedure

Working with Working with traumatized families: traumatized families:

attachment theory attachment theory approachapproach

Raija-Leena Punamäki, University of Raija-Leena Punamäki, University of TampereTampere


””War and attrocities destroy War and attrocities destroy homes”:homes”:

Concrete: e.g. 17 600 persons’ Concrete: e.g. 17 600 persons’ homes destroyed in Gaza 2001-2004 homes destroyed in Gaza 2001-2004

Many pregnant women & mothers Many pregnant women & mothers with infants live in tents & houses with infants live in tents & houses of relativesof relatives

Symbolic: The question of security Symbolic: The question of security & safety& safety


ImportanceImportance of early motherhood of early motherhood

Mother anxiety in pregnancy > more Mother anxiety in pregnancy > more attention deficit, reading difficulties attention deficit, reading difficulties

Mother depression in post-partum > Mother depression in post-partum > aggressive & depressive symptoms aggressive & depressive symptoms

in preschoolin preschool Epidemiology: mothers pregnant in Epidemiology: mothers pregnant in

war (Israel 1967) > more aggressive war (Israel 1967) > more aggressive & depressive symptoms in middle & depressive symptoms in middle childhood childhood



Importance of the first year Importance of the first year

The first relationship with mother The first relationship with mother creates inner models of: creates inner models of:

Whether safe place is available Whether safe place is available How to avoid rejection How to avoid rejection Whether to trust others and selfWhether to trust others and self How to express distress How to express distress Whether to dare exploreWhether to dare explore


Importance of Attachment Importance of Attachment

The attachment a condition to survival The attachment a condition to survival Attachment behavior activates when Attachment behavior activates when

experience of danger and threat: experience of danger and threat: IInfancy:stranger & separation nfancy:stranger & separation Preschool: symbolic & real fearsPreschool: symbolic & real fears Middle childhood: rejection & incompetenceMiddle childhood: rejection & incompetence Adolescence: intimate relationships & Adolescence: intimate relationships & futurefuture Adulthood: transition periods & stress & Adulthood: transition periods & stress & change change


Attachment stylesAttachment styles in childhood in childhood

AttachmentAttachmentstylestyle

Safe-Safe-seekingseeking

ExploratioExplorationn

EmotionalEmotionalresponsesresponses

Secure Secure Seeks Seeks consolingconsoling

Active &Active &curiouscurious

AdequateAdequatedistress, but distress, but calming calming downdown

Insecure-Insecure-avoidant avoidant

Not Not seekingseeking

Active & Active & self-self-reliantreliant

No distress No distress & self-& self-sufficientsufficient

Insecure-Insecure-ambivalentambivalent Clinging Clinging

&&obsessedobsessed

Not dare Not dare to exploreto explore

Strong Strong expre.expre.Not calmingNot calmingdowndown

Dis-Dis-organisedorganised Not clearNot clear

patternpatternattachmeattachmentnt

Distress &Distress &oscillating oscillating


Secure attachment style & Secure attachment style & emotional developmentemotional development

StrenghtsStrenghts• Inner model about the availability of care Inner model about the availability of care • Experience of a mother’s sensitivity to interpret Experience of a mother’s sensitivity to interpret

her/his feelings in right way her/his feelings in right way • Feels secure enough to express strong, real and Feels secure enough to express strong, real and

also negative feelingsalso negative feelings• A rich variety (repertoire) of feelings A rich variety (repertoire) of feelings • Knowledge that bad feelings can be calmed down Knowledge that bad feelings can be calmed down • Internalized picture about how emotions can be Internalized picture about how emotions can be

expressed and controlled expressed and controlled VulnerabilitiesVulnerabilities


Avoidant attachment & Avoidant attachment & emotional developmentemotional development

Vulnerabilities Vulnerabilities • Experiences of rejection & disappointment Experiences of rejection & disappointment • Difficultiy to recognize own emotionsDifficultiy to recognize own emotions• Over control of emotions, ’too polite’Over control of emotions, ’too polite’• Falsified positive feelingsFalsified positive feelings• Narrow repertoire of feelingsNarrow repertoire of feelings• Conflicts between physiological (arousal) & Conflicts between physiological (arousal) &

subjective emotional expression subjective emotional expression StrenghtsStrenghts

• Thrust in own coping & managementThrust in own coping & management• High cognitive competence High cognitive competence


Ambivalent & emotional Ambivalent & emotional developmentdevelopment

Vulnerabilities Vulnerabilities • Inner model of the parent as unpredictable, Inner model of the parent as unpredictable,

absent, indifferent or even dangerous absent, indifferent or even dangerous • Difficult to control emotios; undercontrolDifficult to control emotios; undercontrol• Emotions ’flow over’, ’all the time on’Emotions ’flow over’, ’all the time on’• Difficult to be consoled & calm downDifficult to be consoled & calm down• Strong emphasis on emotions, and possible Strong emphasis on emotions, and possible

neglect of cognitive development (thinking, neglect of cognitive development (thinking, reasoning, framing)reasoning, framing)

Strengths Strengths • Repertoire and intensity of emotional Repertoire and intensity of emotional

expressionexpression


Trauma in early ageTrauma in early age

Event Event

Psychological

mechanisms

Expressedsymptoms

Horror, Threat, Danger • Arousal• Sensitivity

to danger • Sensomotor memory

• No episodes • Narroved perceptions

• Biased interpretatios

No integration of feeling & knowing

•Nightmares•Excessive fears•Intrusions•Arousal


Interaction between mother and Interaction between mother and infantinfant

Also the child has influence on the Also the child has influence on the interaction >> reciprocal relations interaction >> reciprocal relations (Infant research)(Infant research)

The fit between the mother’s and The fit between the mother’s and baby’s temperemant >> genetics baby’s temperemant >> genetics provide possibility (goodness-of-fit)provide possibility (goodness-of-fit)

Interactional experiences accumulate Interactional experiences accumulate >> positive or negative >> positive or negative developmental paths start earlydevelopmental paths start early


Traumatic experiencesTraumatic experiences

People have inner reflective response People have inner reflective response models to threatening situationsmodels to threatening situations

procedural (body) and episodic procedural (body) and episodic (emotional) memory systems (emotional) memory systems develope early (associative brain; develope early (associative brain; limbic systems)limbic systems)

no direct link to the semantic no direct link to the semantic (intellectual) memory (cortex (intellectual) memory (cortex developes slowly)developes slowly)


Fear reactions in infants Fear reactions in infants generalizegeneralize

Reaction sensitivity (cryig, distress): Reaction sensitivity (cryig, distress): easyly cries->protesting->defending-easyly cries->protesting->defending-

>aggression>aggression

Dissosiation processDissosiation process:: when crying does not bring consoling: when crying does not bring consoling:

avoiding crying --> compulsive avoiding crying --> compulsive obediency (freezing) -> dissosiation obediency (freezing) -> dissosiation (non connecting feelings and behavior)(non connecting feelings and behavior)


Mother-child at Risk: Intervention Mother-child at Risk: Intervention effectivenesseffectiveness

- Content: psychoeducational at homeContent: psychoeducational at home- Infant-led, Infant-led, - Promoting parent-child communicationPromoting parent-child communication- Focusing on the infant idiosyncronatic Focusing on the infant idiosyncronatic

cues; cues; - Feedback; maternal self-confidence;Feedback; maternal self-confidence;- Comprehensive (all levels of infant Comprehensive (all levels of infant

development)development)- Long periodLong period- Taylored specially to particular riskis!!Taylored specially to particular riskis!!


Mother-child at Risk: Intervention Mother-child at Risk: Intervention effectivenesseffectiveness

• Similar results as usually preventive interventions (mean effect size 0.34)

• More succesful with the first time mothers (es 0.87)

(Review: Fonagy, 2000)


Interventios: What can be Interventios: What can be changed? How? When? By changed? How? When? By

whom?whom?ExperiencesExperiences

MaturationMaturation

Physiological

Psycho-motor

Cognitive

Emotional

Social

•reflects•growing •coordination

•attention•consistency

•speaking

•memory: procedural &

verbal

•recognition of emotions

•attachment •emotional expression •empathy

•friendship


””Torture interferes fatherhood”Torture interferes fatherhood”

Oslo agreement (Israel & PLO, 1993): Oslo agreement (Israel & PLO, 1993): 8 000 political prisoners free8 000 political prisoners free

Torture systematic in Israeli prisonons (Landau: Torture systematic in Israeli prisonons (Landau: slight psychological pressure)slight psychological pressure)Motivation for seeking psychological help: Motivation for seeking psychological help:

* anger & intrusive memories harm intimate* anger & intrusive memories harm intimate relationship relationship * feeling failure in being a father: outsider * feeling failure in being a father: outsider * numbing of feelings* numbing of feelings (not so much for PTSD)(not so much for PTSD)


Trauma in adulthoodTrauma in adulthood

Working modelsWorking models oneselfoneself other people other people worldworld

Traumatic experience Depression

PTSDSomatization

Mental Health

Therapy??© Raija-Leena Punamäki 2007


Attachment theoryAttachment theory: Adults: Adults(J. Bowlby, M. Ainsworth, M. Main, P. Crittenden)(J. Bowlby, M. Ainsworth, M. Main, P. Crittenden)

Understand the role of early relations Understand the role of early relations in shaping current functioning in shaping current functioning

Inner working models Inner working models (representations) of oneself, trusting (representations) of oneself, trusting others & safetyothers & safety

Cumulative development: Attachment Cumulative development: Attachment style organizes behaviour, emotions, style organizes behaviour, emotions, cognitions & relationships cognitions & relationships


Memory types Memory types (Tulving) (Tulving)

Sensory memory: visual (icon), auditory Sensory memory: visual (icon), auditory (echo), smell, taste(echo), smell, taste

Semantic memory: ”Copenhagen is in Semantic memory: ”Copenhagen is in DK”, ”People are basicly good” DK”, ”People are basicly good”

Episodic & narrative memory: events, Episodic & narrative memory: events, stories, jokesstories, jokes

Prosedural memory: kinesthetic, Prosedural memory: kinesthetic, emotional states, ”body remembers” emotional states, ”body remembers”


Adult Attachment: Adult Attachment: Vulnerability & ResourcesVulnerability & Resources

Secure-balancedSecure-balanced

Innocent expectations of the world, naivityInnocent expectations of the world, naivityLack of ’training’ with hardshipsLack of ’training’ with hardships

Integrated & coherent memoriesIntegrated & coherent memories Both episodic & semantic memoryBoth episodic & semantic memory Access to unconscious processes Access to unconscious processes Realistic perceptions of eventsRealistic perceptions of events Reliance on others for helpReliance on others for help



Insecure-dismissingInsecure-dismissing

Semantic memory predominatesSemantic memory predominates Procedural memory of trauma & lack of childhood Procedural memory of trauma & lack of childhood

memoriesmemories Distrust of others & social withdrawal Distrust of others & social withdrawal Minimize emotions, deny pain Minimize emotions, deny pain

Thrust in oneself Thrust in oneself Interest in intellectual tasks Interest in intellectual tasks



Insecure-preoccupiedInsecure-preoccupied Emotional & narrative memories, incoherent Emotional & narrative memories, incoherent Semantic memory, narrow Semantic memory, narrow Past dominates & recurring feeling statesPast dominates & recurring feeling states Dependency & disappointment of othersDependency & disappointment of others Ambivalent & conflicting relationsAmbivalent & conflicting relations

Intensive expression of emotions Intensive expression of emotions Social commitmentSocial commitment


ArgumentsArguments

Attachment is about protection from Attachment is about protection from dangerdanger

Danger and trauma activate and Danger and trauma activate and crystallize responses typical to each crystallize responses typical to each attachment styleattachment style

Therapy with trauma victims should be Therapy with trauma victims should be tailored either to match tailored either to match oror to to compensate the unique vulnerabilities compensate the unique vulnerabilities and strengthsand strengths


ParticipantsParticipants of the study of the study

153 153 Palestinian Palestinian men, Gazamen, Gaza

Political Political prisonersprisoners

Intifada I Intifada I 1987-19931987-1993

Local Local clinicsclinics


Study IStudy I

Attachment & Trauma-related Attachment & Trauma-related Emotions Emotions


Adult Attachment & emotionsAdult Attachment & emotionsSecure-balancedSecure-balanced Access to both negative & positiveAccess to both negative & positive Access to both emotions & cognitionAccess to both emotions & cognitionInsecure-dismissingInsecure-dismissing Distrust emotions; minimizes feelingsDistrust emotions; minimizes feelings Emphasis on analytic & cognitive modeEmphasis on analytic & cognitive modeInsecure-preoccupiedInsecure-preoccupied Distrust cognitions, ignores informationDistrust cognitions, ignores information Emotions overwhelmingEmotions overwhelming


Multilevel Model ofMultilevel Model of EmotionsEmotions (N.Fridja)(N.Fridja)

Domains of emotionsDomains of emotions Behavioural: action readinessBehavioural: action readiness Cognitive: appraisal & metacognitionsCognitive: appraisal & metacognitions Affective: feelings, mood Affective: feelings, mood Physiological level: arousalPhysiological level: arousalIntensity and valence of emotionsIntensity and valence of emotions Negative and positive Negative and positive Content & autobiographical meaningContent & autobiographical meaning


Study Hypotheses:Study Hypotheses:

Emotional processing of trauma is distorted Emotional processing of trauma is distorted among insecurely attached individuals:among insecurely attached individuals:

DismissingDismissing use predominantly cognitive use predominantly cognitive modesmodes

PreoccupiedPreoccupied use predominantly emotional use predominantly emotional feeling statesfeeling states


SecureSecure individuals use balanced individuals use balanced emotional-cognitive processingemotional-cognitive processing

Exposure to trauma activates the Exposure to trauma activates the attachment-specific emotional attachment-specific emotional processing processing




ConclusionConclusionss

Secure, DismissingSecure, Dismissing & & PreoccupiedPreoccupied persons have unique resources andpersons have unique resources and vulnerabilitiesvulnerabilities

Integrating traumatic experiences asIntegrating traumatic experiences as a part of personal history a part of personal history

The aim of therapy is to balance The aim of therapy is to balance between cognitive and emotional between cognitive and emotional processing processing


ConclusionConclusionss

Insecure attachment is Insecure attachment is not not an inherent an inherent risk for psychopathology risk for psychopathology Secure attachment is Secure attachment is not not a general a general ’protective factor’’protective factor’ The The nature of traumanature of trauma is decisive: is decisive: ”degree of intimacy” ”degree of intimacy” Activation Activation of danger-related working of danger-related working models is informativemodels is informative


Therapy & Interventions should Therapy & Interventions should be tailored accordinglybe tailored accordingly DismissingDismissing clients ”feel home” withclients ”feel home” with semantic-causal mode; semantic-causal mode; important to learn to recognize,important to learn to recognize, express and value feelingsexpress and value feelings

PreoccupiedPreoccupied clients escalate emotional clients escalate emotional responses and ignore cognitive cues;responses and ignore cognitive cues; therapy should integrate therapy should integrate both modalitiesboth modalities

Secure Secure clients often satisfy withclients often satisfy with psychoeducational approachpsychoeducational approach


Study IIStudy IIAttachment & Working alliance Attachment & Working alliance

Working alliance = bonding & goal Working alliance = bonding & goal setting in the therapy setting in the therapy

Good alliance predicts successful Good alliance predicts successful therapy outcomes therapy outcomes

Changes in alliance predicts good Changes in alliance predicts good outcomes outcomes


Before therapy During therapy After therapy

PERSONALITY ?Adult attachment

?Defence styles

THERAPY PROCESS ?Alliance

?Significant events

?Feeling states

EMOTIONAL-COGNITIVE

PROCESSING

?Self- and object representations



?Emotional re-sponses

?Dreaming ?Emotional re-sponses

MENTAL HEALTH ?PTSD ?PTSD ?PTSD

?Somatic symp-toms

?Somatic sym p-toms

?Soma tic symp-toms

?Personal growth ?Personal growth ?Personal growth

Reseach Setting and Procedure


Research settingResearch setting

at the at the beginninbeginnin

ggafter 5 after 5 monthsmonths

after 10after 10monthsmonths

Individual Individual therapytherapy 2727 1717 1515Group Group therapy therapy 2525 2525 2525No therapyNo therapy 100100 7070 7070


Development of Development of Working Alliance Working Alliance

according to Attachmentaccording to Attachment

1,4

1,6

1,8

2

2,2

At the beginning In the middle At the end

Therapy accross One Year

AutonomousDismissingPreoccupied


Results on Working AllianceResults on Working Alliance PTSD symptoms decrease in intensive, PTSD symptoms decrease in intensive, focused, individual treatment onlyfocused, individual treatment only

Attachment style is important in forming Attachment style is important in forming working alliance working alliance

DismissingDismissing clients dislike disclosure & clients dislike disclosure & sharing emotions -> poor alliance at the end of sharing emotions -> poor alliance at the end of therapy.therapy. Feels home in cognitive domains -> good Feels home in cognitive domains -> good alliance at the middle of therapyalliance at the middle of therapy

Preoccupied Preoccupied clients ’attach’ quickly, clients ’attach’ quickly, disappoint quickly -> diminishing alliancedisappoint quickly -> diminishing alliance -> very good alliance at the end -> very good alliance at the end


Therapy & Interventions should Therapy & Interventions should be tailored accordinglybe tailored accordingly DismissingDismissing clients ”feel home” clients ”feel home” with semantic-causal mode; with semantic-causal mode; important to learn to recognize,important to learn to recognize, express and value feelingsexpress and value feelings

PreoccupiedPreoccupied clients escalate clients escalate emotional responses andemotional responses and ignore cognitive cues;ignore cognitive cues; therapy should integrate therapy should integrate both modalitiesboth modalities


Paper-and-pencil measure, based on the Paper-and-pencil measure, based on the AAIAAI

Descriptions of childhood relationship Descriptions of childhood relationship with motherwith mother and father and father

Descriptions of events of being ill, Descriptions of events of being ill, upset & rejected as a childupset & rejected as a child

Descriptions of memories of distress Descriptions of memories of distress & separation& separation

Measurements:Attachment variables I


Cluster analysis of attachment patternsCluster analysis of attachment patternsWhat is remembered?What is remembered? Childhood memories of love, Childhood memories of love,

rejection, neglect, over-involvement, rejection, neglect, over-involvement, pressure to achievepressure to achieve

Dealing with distress: denial, Dealing with distress: denial, withdrawal, aggression, self-reliance, withdrawal, aggression, self-reliance, seeking attention, consoling & seeking attention, consoling & supportsupport

Measurements:Attachment variables II


How the experiences are remembered?How the experiences are remembered? Coherence of the answers: succinctly, Coherence of the answers: succinctly,

truthfully, clearly & logically describedtruthfully, clearly & logically described General incoherence General incoherence Current anger, idealization & Current anger, idealization &

dderogation erogation Memory modalities: semantic, Memory modalities: semantic,

episodic, & sensory memories, & episodic, & sensory memories, & narrative quality and feelings narrative quality and feelings

Measurements:Attachment variables III


Harvard Trauma Questionnaire (HTQ)Harvard Trauma Questionnaire (HTQ) (Mollica &Caspi-Yavin, 1991)(Mollica &Caspi-Yavin, 1991)Intrusion; Avoidance, HyperarousalIntrusion; Avoidance, Hyperarousal

Somatic symptoms Somatic symptoms (Allodi, 1985)(Allodi, 1985)

psychosomatic, aches, cardiological problemspsychosomatic, aches, cardiological problems

Positive growthPositive growth (Callhoun, 1992)(Callhoun, 1992)personal strength, relating to others, personal strength, relating to others, spiritualityspirituality

Happiness of marriageHappiness of marriage

Measurements:Outcome variables


Experiences of Torture &Experiences of Torture & ill-treatment ill-treatment

Physical Physical Beating hands and legsBeating hands and legs Jumping on the bodyJumping on the body Torture by application Torture by application

of electricityof electricity Burning with cigarettesBurning with cigarettes Breaking bonesBreaking bones ‘‘Crucification’ (hanging Crucification’ (hanging

from hands)from hands) ‘‘Falanga’ (beating on Falanga’ (beating on

feet bottom?)feet bottom?) Suffocating Suffocating

Psychological Psychological Personal humiliationPersonal humiliation Threats towards family Threats towards family

membersmembers Threats to cause Threats to cause

infertilityinfertility Confronted by false Confronted by false

accusationsaccusations Sham executionSham execution Forced confession or Forced confession or

‘singing’ ‘singing’ Forced to witness Forced to witness

torture of otherstorture of others


Experiences of torture &Experiences of torture & ill-treatment ill-treatment

Sexual Sexual Sexual Sexual

harassmentharassment Beating on the Beating on the

sexual organssexual organs Attempted rapeAttempted rape Threats to rape Threats to rape

wife or sisterwife or sister

Sensory violation Sensory violation HoodingHooding Exposure to strong Exposure to strong

light light Isolation and solitary Isolation and solitary

confinementconfinement Food/water Food/water

deprivationdeprivation


Argument: war makes children Argument: war makes children aggressiveaggressive


Development of aggressionDevelopment of aggression I I

When are we the most aggressive?When are we the most aggressive? Peak of physical aggression 3.4 yearsPeak of physical aggression 3.4 years Boys: physical aggression & verbal Boys: physical aggression & verbal

aggression girls 12-14 years, the aggression girls 12-14 years, the decreasedecrease

Adolescence aggression >>> depression Adolescence aggression >>> depression in adulthoodin adulthood

Pre-school aggression >>> antisocial, Pre-school aggression >>> antisocial, pathology, criminal pathology, criminal


Development of aggressionDevelopment of aggression I I

Kinder-garten age: Kinder-garten age: Physical aggression dominant Physical aggression dominant

(biting, hitting, fights about toys) (biting, hitting, fights about toys) Changes to verbal aggression – Changes to verbal aggression –

direct to undirect direct to undirect Middle childhood Middle childhood Girls: verbal and indirect aggressionGirls: verbal and indirect aggression Boys: physical aggressionBoys: physical aggressionAdolescents: DecreasesAdolescents: Decreases


Explanation models for Explanation models for aggressive behavior aggressive behavior

Fear –modell: Fear –modell: * need for great stimulus & excitement * need for great stimulus & excitement * punishment is effective * punishment is effective Empathy deficient: Empathy deficient: * difficulty to recognize other people’s * difficulty to recognize other people’s

feelingsfeelings * Interprets sadness & fear as hate* Interprets sadness & fear as hate Regulation Regulation * Escalaton & lack of control of anger* Escalaton & lack of control of anger


Individual & social Individual & social aggressionaggression

Children are differently ’vulnerableChildren are differently ’vulnerable No good or bad childrenNo good or bad children Parent-child relationship: punishment Parent-child relationship: punishment

or discussion, model or orderor discussion, model or order Risk for aggression:Risk for aggression: * what we see & how we see* what we see & how we see * interpretation & explanation * interpretation & explanation Aggressive behavior is revarded Aggressive behavior is revarded


Interventions with Interventions with aggressionaggression

Intervention & prevention aggression Intervention & prevention aggression is based on ’mediation from is based on ’mediation from vitnessing violence to becoming vitnessing violence to becoming violentviolent

1) recognition & interpretation1) recognition & interpretation 2) regulation 1,2,32) regulation 1,2,3 3) alternative behavior3) alternative behavior 4) understanding causes4) understanding causes 5) Humor & stories & narratives


Prevention of aggression Prevention of aggression

Individual & groupIndividual & group: Recognition & : Recognition & discrimination of emotions: sad, fear, discrimination of emotions: sad, fear, surprisesurprise

Training of causes & consequencesTraining of causes & consequences Relations: parents, peers, siblingsRelations: parents, peers, siblings Community: Community: No tolerance for violence No tolerance for violence Clear rules for behaviorClear rules for behavior Alternatives exist Alternatives exist Political level:Political level: no victims, no no victims, no

humiliation, no acceptance of humiliation, no acceptance of revencerevence


Breaking the violent circle Breaking the violent circle Before interventionBefore intervention Not recognize own Not recognize own

excitementexcitement Interpret others as Interpret others as

threatening threatening Emotions run quicklyEmotions run quickly Impossible to Impossible to

controlcontrol Does not remember Does not remember

own aggressionown aggression Behaves without Behaves without

thinking thinking

After InterventionAfter Intervention Learn how stages of Learn how stages of

’excitement’ ’excitement’ develope develope

Feelings base on Feelings base on ’reality’’reality’

Feelings slow tempoFeelings slow tempo Conscious controlConscious control Memory of Memory of

alternative behavioralternative behavior Behavior, feeling, Behavior, feeling,

thinking ”bird level”thinking ”bird level”


Need for Intervention TargetingNeed for Intervention Targeting Intervention studies with community-Intervention studies with community-

sample method: More pronounced sample method: More pronounced intervention effects e.g. most benefits intervention effects e.g. most benefits for at-risk familiesfor at-risk families (Olds 2002; Lee 2003)(Olds 2002; Lee 2003)

Call for more targeted intervention Call for more targeted intervention programs fore such familiesprograms fore such families

Authors of at-risk intervention Authors of at-risk intervention programmes still call after more programmes still call after more research of targeting e.g. underlying research of targeting e.g. underlying mechanisms and timing influencesmechanisms and timing influences (Seitz (Seitz et al. 1985, Booth et al. 1992, Black et al. 1994, et al. 1985, Booth et al. 1992, Black et al. 1994, Dybdahl 2001, Kok et al. 2004). Dybdahl 2001, Kok et al. 2004).


Need for Intervention TargetingNeed for Intervention Targeting Intervention studies with community-Intervention studies with community-

sample method: More pronounced sample method: More pronounced intervention effects e.g. most benefits intervention effects e.g. most benefits for at-risk familiesfor at-risk families (Olds 2002; Lee 2003)(Olds 2002; Lee 2003)

Call for more targeted intervention Call for more targeted intervention programs fore such familiesprograms fore such families

Authors of at-risk intervention Authors of at-risk intervention programmes still call after more programmes still call after more research of targeting e.g. underlying research of targeting e.g. underlying mechanisms and timing influencesmechanisms and timing influences (Seitz (Seitz et al. 1985, Booth et al. 1992, Black et al. 1994, et al. 1985, Booth et al. 1992, Black et al. 1994, Dybdahl 2001, Kok et al. 2004). Dybdahl 2001, Kok et al. 2004).


Methodological consideration of Methodological consideration of community vs. at-risk samplescommunity vs. at-risk samples

Community based/Primary/Universal Interventions

Risk-group/Focused/Secondaryinterventions

In a phase of data-analyzing

Selected risk-group cases


The confusion of what has been done The confusion of what has been done (inside the intervention)(inside the intervention)

””Much remains to be determined about Much remains to be determined about targeting, timing and spesific procedures that targeting, timing and spesific procedures that are effective” are effective” (Seitz et al. 1985)(Seitz et al. 1985)

””How How the intervention worked, however is the intervention worked, however is unknown, and more research is needed to unknown, and more research is needed to investigate the working factors in this investigate the working factors in this approach” approach” (Dybdahl 2001)(Dybdahl 2001)

” ” Addtional information is necessary to Addtional information is necessary to identify identify how how environmental factors facilitate environmental factors facilitate and maintain positive change” and maintain positive change” (Black et al. 1994)(Black et al. 1994)


The confusion of critical variables The confusion of critical variables (between the interventions) (between the interventions) Fonagy Fonagy

19981998 The center of the intervention: child or The center of the intervention: child or

parent parent Starting point of the intervention: during Starting point of the intervention: during

pregnancy or at birth or during childhood,pregnancy or at birth or during childhood, Administration of intervention: nurses or Administration of intervention: nurses or

psychologists or other professionals or psychologists or other professionals or volunteers, volunteers,

Orientation of intervention: focused or Orientation of intervention: focused or broad-based/ educational or behavioral or broad-based/ educational or behavioral or relationship or psychodynamical relationship or psychodynamical


What should be done?What should be done? ” ” Vast resources are spent on aid programs. For Vast resources are spent on aid programs. For

ethical as well as economical reasons it is important to ethical as well as economical reasons it is important to know know whatwhat works best works best whenwhen and and for whom. for whom. Therefore, Therefore, in spite of the obstacles, well-designed and lareger in spite of the obstacles, well-designed and lareger scale evaluation studies are needed” scale evaluation studies are needed” (Dybdahl 2001)(Dybdahl 2001)

““The growing literature on prevention makes it The growing literature on prevention makes it necessary to evaluate the impact of different necessary to evaluate the impact of different programs and determine which factors promote better programs and determine which factors promote better outcomes. “ outcomes. “ ((Durlak & Wells 1998)Durlak & Wells 1998)

We are still on the way of developing the full potential We are still on the way of developing the full potential of prevention of prevention (Olds, 2002),(Olds, 2002), and on this road we will and on this road we will need a guidance of scientific framework.need a guidance of scientific framework.


Classifications of preventions Classifications of preventions (physical illness)(physical illness)

PrimaryPrimarydecreasing the number of decreasing the number of new cases of a disordernew cases of a disorder

1957 Comission of 1957 Comission of Chronic IllnessChronic Illness

SecondarySecondary lowering the rate of lowering the rate of

established cases of the established cases of the disorder in the populationdisorder in the population

TertiaryTertiarydecreasing the amount of decreasing the amount of

disability associated with an disability associated with an existing disorder .existing disorder .

UniversalUniversalgeneral public and for all general public and for all

members of specific eligible members of specific eligible groups, such as pregnantgroups, such as pregnant

women women

1983 Gordon (population 1983 Gordon (population groups to whom groups to whom interventions are interventions are

directed)directed)

SelectiveSelectivesubgroup of the population subgroup of the population whose risk of becoming ill is whose risk of becoming ill is

above average above average

IndicatedIndicatedpersons who are found to persons who are found to manifest a risk factor that manifest a risk factor that identifies them as being at identifies them as being at

high risk for the future high risk for the future developmendevelopmenof a disease. of a disease.


Classifications of preventions Classifications of preventions (mental illness)(mental illness)

UniversalUniversalgeneral public or a whole population general public or a whole population

group that has not been identified on the group that has not been identified on the basis of individual riskbasis of individual risk

IOM 1994IOM 1994SelectiveSelective

individuals or a subgroup of the individuals or a subgroup of the population whose risk of developing population whose risk of developing

mental disorders is significantly higher mental disorders is significantly higher than averagethan average

IndicatedIndicatedhigh-risk individuals who are identified high-risk individuals who are identified

as having minimal but detectable signs or as having minimal but detectable signs or symptoms foreshadowing mental symptoms foreshadowing mental

disordersdisorders

1.1.participants who have no current participants who have no current

symptoms of mental disorder and were never symptoms of mental disorder and were never symptomaticsymptomatic

NIMH Workgroup of Mental Disorders NIMH Workgroup of Mental Disorders Prevention Research 1998Prevention Research 1998

2. 2. participants who have current sub-clinical participants who have current sub-clinical symptomssymptoms

3.3.participants who participants who

have currently have currently diagnosed disorderdiagnosed disorder

and/or were and/or were previously previously

symptomatic >the symptomatic >the emphasis is on emphasis is on

preventionpreventionof relapse or of relapse or

recurrencerecurrence

4.4. participants participants

who have a currently who have a currently diagnosed disorder, diagnosed disorder,

with thewith theemphasis on emphasis on

prevention of prevention of comorbidity or comorbidity or

disabilitydisability

Primary / UniversalPrimary / Universalimproving child development, parenting improving child development, parenting

knowledge and behaviour, and infant knowledge and behaviour, and infant mental health for all families within their mental health for all families within their

service rangeservice range

Zeanah et al. 2005Zeanah et al. 2005Focused / TargetedFocused / Targeted

specifically identified groups considered specifically identified groups considered at risk for developing potentially serious at risk for developing potentially serious

social or emotional problemssocial or emotional problems

Intensive / TertiaryIntensive / Tertiaryinfants and caregivers experiencing infants and caregivers experiencing

current difficulties, and also attempt to current difficulties, and also attempt to prevent or lessen future problemsprevent or lessen future problems


The mental health intervention The mental health intervention spectrum for mental disorders.spectrum for mental disorders.

(IOM 1994)(IOM 1994)


...Classifications of preventions (mental illness) ...Classifications of preventions (mental illness)

Durlak & Wells 1997Durlak & Wells 1997 Intervention PopulationIntervention Population

PersonPerson

directly to the directly to the target populationtarget population

EnvironmentEnvironment

attemp to change attemp to change individuals individuals

indirectly by indirectly by modifying the modifying the environmentenvironment

Universal/ Global/ Universal/ Global/ Population widePopulation wide

all members in all members in available available populationpopulation

At-risk groupsAt-risk groups

groups considered groups considered at risk for eventual at risk for eventual problems, but who problems, but who are not yet are not yet dysfunctionaldysfunctional

Groups with Groups with stressful life stressful life events or events or transitionstransitions

Brown & LiaoBrown & Liao19991999

Intervention Population Intervention Population Selection of effective intervention Selection of population at risk Selection of effective intervention Selection of population at risk according to population and disorderaccording to population and disorder at handat hand

Documents

How family members express psychological distress & resources in war trauma? Raija-Leena Punamäki, University of Tampere, Finland & Samir Qouta & Eyad