Family Treatment When A Member Has PTSD
By Don R. Catherall, Ph.D.
NCP Clinical Quarterly 7(2): Spring 1997
The treatment of a family containing a traumatized member, as in all family treatment, is initially defined by the presenting problem. Unlike many forms of individual therapy, families rarely remain in treatment if they can not see its immediate relevance to the concerns which brought them to seek help. Though we may view a family's problems as a result of traumatization, we will not be permitted to successfully probe the trauma unless the family can be helped to see how the presenting problem(s) is linked to the traumatization. When the family therapist can demonstrate such a link, he or she then has a mandate to pursue the trauma-related material (1).
A Member With PTSD Is A Family Problem
One untoward result of demonstrating the link with the trauma is that the traumatized member can come to be seen as the problem or as carrying the problem. This view is counterproductive; it can interfere with the family's capacity to bring all its resources to bear on the problem. The families that cope best tend to view afflictions of individual members as a problem for the entire family (2). The therapist counters the individual locus of the problem by operating on the premise that it is a problem facing the entire family and by directly confronting any scapegoating maneuvers by other family members.
Assume A Non-Pathological Point Of View
A supportive family is the best recovery environment for a trauma survivor; the first goal of family therapy is simply to facilitate the natural recovery process. The therapist operates according to a "health premise", assuming the family is healthy and will follow appropriate guidance until proven otherwise (3). However, when the family is unable to provide the right environment, despite the therapist's education and direction, the therapist must seek to correct dysfunctional patterns which may have existed prior to the trauma.
Goals Of Family Therapy
The therapy may focus on facilitating the recovery of the affected member, dealing with the secondary traumatization of other members, and/or changing the environment of the entire family system. These issues generally develop in chronological order, depending upon the effectiveness of the family structure and coping strategies prior to the traumatic event. If the traumatization is recent, then the effects may be confined to the survivor(s). The longer the family has lived with a traumatized member, the greater the likelihood that other members are affected. If the traumatized member's symptoms have reached chronic levels, the entire family environment is probably affected.
Acute PTSD and the role of the family
The tasks of the family--and the therapy--are initially defined by the affected member's stage of recovery. The primary task for the family during the acute stage of an individual's recovery from traumatization is to provide support. Sometimes the affected member withdraws from the world for a period of time and needs to be protected from the demands and stresses of ordinary life. At such times, it is appropriate that the family provide a sanctuary from the world, participating in Lindy's "trauma membrane" (4). The therapeutic task at this stage is to facilitate the family's provision of support by educating the family, normalizing the affected member's reactions, and removing obstacles to the provision of support.
This brief sanctuary can turn into an obstruction to further progress if the pattern becomes set and the affected member is viewed as permanently disabled. This development can interfere with the next stage of recovery in which the affected member begins to re-engage with normal life tasks. If the family is stuck at this stage, the therapeutic task is to help the family change the once supportive pattern and challenge the affected member to re-engage with normal life tasks.
The longer the time span following the traumatization of one member, the greater the likelihood that other members of the family will be affected. Family members may minimize their own distress and be reluctant to seek support. At this stage, the therapeutic task is to normalize the secondary traumatization and give other affected members the opportunity to openly discuss and work through their reactions.
Chronic PTSD and the traumatized family
The more that a family's basic survival as a functioning, cohesive group is threatened, the more hampered the family becomes in providing care for individual members. When the PTSD reaches chronicity, the family's focus often moves beyond the provision of support for the affected member(s) and can be said to be primarily oriented around the survival of the family. The therapeutic tasks now focus on changing the core environment of the family. The family must be helped to: (a) create and maintain an atmosphere of safety, (b) provide for the care of all members, (c) develop and/or preserve a connection with the larger community, (d) replace ineffective coping skills, and (e) overcome the traumatic sequelae, including myths, rules, a dysfunctional world view, and reenactments of the trauma.
Intervening
Once the goals of the therapy are identified, they should be shared with the family. The support goals of the acute stage often continue into the later stages. The following areas of intervention are intended to capture the range of difficulties encountered when the entire family environment is adversely affected. Using a psychoeducational approach, the therapist can openly identify these problem areas with the family and establish a collaborative alliance, as well as a mandate to pursue these areas. As with individual post-traumatic therapy, the therapist conveys the essential normality of the difficulties that the family is experiencing (5).
Creating an atmosphere of safety
The family's first priority following traumatization of one or more members is to re-achieve a sense of stability and safety. Physical safety is often a concern, particularly with children and traumatized members. Fearful family members will not feel safe if they feel that their fears are not being taken seriously. Many families deal with fears through denial and/or dismissive reassurances ("Don't worry, there's nothing to be afraid about."). If this is occurring, the therapist must (a) help the fearful members express their fears and (b) help the other members listen and respond appropriately. Sometimes, physical actions will be required (replacing locks, installing smoke detectors, taking defense classes, etc.), but the first step is to ensure that fearful members feel their concerns are taken seriously. Traumatized children may remain in the alarm state if they feel their fears are not being addressed. This extended state of arousal in children must be attenuated as quickly as possible as it can lead to a host of problems in neurological development (6-7).
The other dimension of safety is psychological. Traumatization can stir powerful feelings of alienation and shame. Unfortunately, many people do not deal well with shame and resort to distancing and blaming maneuvers to protect themselves. In any group, this can result in the sacrifice of some members, who either internalize the shame or act out destructively (8). The therapist must interrupt all instances of shaming and blaming and help family members maintain their acceptance of one another.
Providing for the care of all family members
When the family environment is affected, the family's ability to take care of its members is disrupted. The emotional inaccessibility, particularly of the parents, leads to a lack of attunement to the emotional needs of family members (9-10). The therapist must help the family members use the safety of the therapy sessions to: (a) express feelings and needs that have gone unexpressed, and (b) to hear and respond to each other's emotional needs.
When the parents are unable to fulfill their parenting functions, they leave significant gaps in areas such as nurturance, modeling, limit-setting, and resource management. Generally, one or more of the children takes on the role of parentified child and performs some or all of these functions. These children mature into caretaker adults, more attuned to others' needs than to their own. The therapist must intervene, often using a structural approach, to remove children from inappropriate roles and empower the parents to do their job.
Connecting with the larger community
The connection to the larger community is a vital resource for every family. When a family has been traumatized, there is a tendency to become withdrawn and distrustful. In a closed family system, the internal reality of the family more easily diverges from that of the surrounding culture. Family members then have difficulty participating in their culture; they are less able to engage in the developmental process of unlearning old ways and learning new ways of being members of society. The family therapist focuses on the closed nature of the family--unearthing the beliefs and attitudes that underlie it and helping the family enhance those connections they already possess.
Replacing ineffective coping strategies
The therapist helps the family replace ineffective coping strategies, such as using mind and mood altering substances or resorting to violence (11). Families must learn to recognize and acknowledge stressors, approaching problems as a family problem and not scapegoating or blaming individual members. They must be openly supportive and communicate in a direct, expressive manner with tolerance for individual differences and few sanctions against how members express themselves.
Overcoming Traumatic Sequelae
In addition to changes in the family environment, the trauma often continues to exert a more direct influence upon the family. The family's view of the world may be permanently affected, sometimes in a manner that is not visible to family members. The family may operate according to myths and rules that relate back to the trauma. Probably the most invasive persistence of the trauma appears in the reenactments that commonly occur in the traumatized family.
Reenactments of the trauma
Individuals with PTSD are prone to reenact the trauma within their families. Victims may experience other family members as perpetrators or apathetic bystanders. Women who have been raped may become fearful of their husbands or irrationally angry at their inability to protect them. Someone who experienced a traumatic loss may react to minor separations as though they are major losses. Sometimes victims become victimizers of other family members. These kinds of reenactments involve the relational aspects of the trauma; other reenactments involve fear of repetitions of the event. Someone who survived an earthquake may keep the entire family in a state of tense apprehension that another disaster is about to occur. A survivor of an auto accident may react to ordinary driving situations as though another accident is happening.
The family therapist's task is to disentangle the other family members from the reenactments, particularly the transference based ones. The therapist first helps the family recognize the link to the trauma. The therapist then may need to help other family members relinquish the roles they have learned to play in the recurring reenactments. Often, the same members play the same roles and come to confuse the roles with their personalities. It can be very liberating for the therapist to be able to see--and help the family see--the healthy person behind the negative role behaviors.
Family myths and rules
Family myths are the lessons that are gleaned from the traumatic events, usually communicated through family stories. Jan Kramer describes how a myth developed following her mother's depression and hospitalization after several family deaths (12). She notes that the traumas elicited a decision not to disagree with or question mother, and that decision had survival value at the time. However, a myth developed that mother was fragile and might die if she did not get her way; consequently, the decision not to disagree with or question her became a permanent, unwritten rule in the family. The rule was adaptive for the few weeks after mother's depressive episode but maladaptive for a permanent way of operating.
The family therapist's task is to search out the significant family stories and give words to the myths and identify the rules that may have evolved out of the family traumas. When family members are able to observe the myths and rules that have ruled their lives, they have more choice over how they will live in the future.
A distorted worldview
When a family has lived very long with the effects of traumatization, many of the family's attitudes and preconceptions can become significantly distorted. These affected dimensions of the family's worldview are particularly evident in familial views about people, their trustworthiness and dependability. An excessively guarded view of the world of people reinforces biases and stereotypes as family members pull back from the world and have fewer opportunities to challenge their preconceptions. This situation is the most resistant to change when the boundary between the family and the community is rigid and closed.
In order to interrupt the family's withdrawal and distortions, the therapist questions some of the family's fundamental assumptions about themselves, other people, human nature, and the meaning of life. This kind of discourse generally occurs at a later stage in the therapy. It cannot occur until safety has been established and the family has gained some awareness of some of the subtle ways in which the trauma has permeated their world. Figley (13) recommends organizing this kind of discussion around the five victim questions: What happened? Why did it happen? Why did we act as we did? Why have we reacted as we have since? What if something like this happens again?
References
1. Pinsof, W.M. (1981). Symptom/patient defocusing in family therapy. In A. Gurman (Ed.), Questions and answers in the practice of family therapy (pp. 50-56). New York: Brunner/Mazel.
2. McCubbin, H.I., & Figley, C.R. (1983). Bridging normative and catastrophic family stress. In H.I. McCubbin and C.R. Figley (Eds.), Stress and the family: Vol. 1. Coping with normative transitions (pp. 218-228). New York: Brunner/Mazel.
3. Pinsof, W.M. (1995). Integrative problem-centered therapy: A synthesis of family, individual, and biological therapies. New York: Basic Books.
4. Lindy, J.D. (1985). The trauma membrane and other clinical concepts derived from psychotherapeutic work with survivors of natural disasters. Psychiatric Annals, 15, 153-160.
5. Ochberg, F.M. (1991). Post-traumatic therapy. Psychotherapy, 1, 5-15.
6. Perry, B.D. (1994). Neurobiological sequelae of childhood trauma: PTSD in children. In M.M. Murburg (Ed.), Catecholamine Function in Posttraumatic Stress Disorder: Emerging Concepts, Washington, D.C.: American Psychiatric Press, 233-255.
7. Perry, B.D., Pollard, R.A., Blakley, T.L., Baker, W.L., and Vigilante, D. (1995). Childhood trauma, the neurobiology of adaptation and 'use-dependent' development of the brain: How states become traits. Infant Mental Health Journal, 16 (4), 271-291.
8. Catherall, D.R. (1995). Coping with secondary traumatic stress: The importance of the therapist's professional peer group. In B.H. Stamm (Ed.), Secondary Traumatic Stress: Self-Care Issues for Clinicians, Researchers, & Educators, Lutherville, MD: Sidran Books, 80-92.
9. Stiver, I.P. (1990). Dysfunctional families and wounded relationships--Part I. Work in Progress, Wellesley, MA: Stone Center Working Paper Series.
10. Catherall, D.R. (In Press). Treating traumatized families. In C.R. Figley (Ed.), Burnout in families: The systemic costs of caring, St. Lucie Press Innovations in Psychology Book Series.
11. Figley, C.R. & McCubbin, H.I. (Eds.) (1983). Stress and the family: Vol. 2. Coping with catastrophe. New York: Brunner/Mazel.
12. Kramer, J.R. (1985). Family interfaces: Transgenerational patterns, New York: Brunner/Mazel.
13. Figley, C.R. (1989). Helping traumatized families. San Francisco: Josey-Bass.
Don R. Catherall is Executive Director of The Phoenix Institute, Chicago's premier trauma institute. Dr. Catherall is an Adjunct Assistant Profess at Northwestern Medical School, where the teaches family therapy and traumatology. He is a member of the Editorial Advisory Board Group of the Journal of Traumatic Stress and the Editorial Board of the electronic journal TRAUMATOLOGYe, and he served for five years on the Department of Veterans Affairs National Advisory Committee on the Readjustment of Veterans of Vietnam and Other Wars.
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