Review Manuscript
Psychological Trauma in the Context of Familial Relationships: A Concept Analysis
TRAUMA, VIOLENCE, & ABUSE 1-11 ª The Author(s) 2017 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1524838017726424 journals.sagepub.com/home/tva
Sophie Isobel1,2, Melinda Goodyear3,4, and Kim Foster5,6
Abstract Many forms of psychological trauma are known to develop interpersonally within important relationships, particularly familial. Within the varying theoretical constructs of psychological traumas, and distinct from the processes of diagnosis, there is a need to refine the scope and definitions of psychological traumas that occur within important familial relationships to ensure a cohesive evidence base and fidelity of the concept in application to practice. This review used a philosophical inquiry methodology of concept analysis to identify the definitions, antecedents, characteristics, and consequences of the varying conceptualizations of psychological trauma occurring within important relationships. Interactions between concepts of interpersonal trauma, relational trauma, betrayal trauma, attachment trauma, developmental trauma, complex trauma, cumulative trauma, and intergenerational trauma are presented. Understanding of the discrete forms and pathways of transmission of psychological trauma between individuals, including transgenerationally within families, creates opportunities for prevention and early intervention within trauma-focused practice. This review found that concepts of psychological trauma occurring within familial relationships are not exclusive of each other but overlap in their encompassment of events and circumstances as well as the effect on individuals of events in the short term and long term. These traumas develop and are transmitted in the space between people, both purposefully and incidentally, and have particularly profound effects when they involve a dependent infant or child. Linguistic and conceptual clarity is paramount for trauma research and practice. Keywords attachment, intergenerational transmission of trauma, memory and trauma, vicarious trauma
Introduction Many of the various forms of psychological traumas are known to develop interpersonally within important human relationships, with a significant difference in effect demonstrated between psychological traumas that occur as a result of environments or events, compared to those that occur over time and across the life span within relationships between people (Forbes et al., 2012; Herman, 1992; Schore, 2002; Van der Kolk, 2014). Trauma that occurs within familial relationships of attachment is known to have particularly profound and complex effects (Siegel, 2001; Steele, 2003). Trauma is simultaneously a precipitant, an action, an agent or mechanism, and an outcome; a word with subtle but significant differences in implied meaning depending on context (Kezelman & Stavropoulos, 2012). In line with its 17th-century Greek origin meaning “wound” (Merriam-Webster, 2016), trauma broadly refers to both physical injury and mental injury. “Psychological trauma” is an umbrella term for the invisible “wounds” or mental injuries that can occur following experiences. Yet how the word “trauma” should be defined is quite problematic (McNally, 2010) due to wide variance in interpretation and meaning. For the purposes of this review, the Substance Abuse and Mental Health Services Administration (2014, p. 7)
definition of psychological trauma is used; psychological trauma results from an event, series of events or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has long lasting adverse effects on the individual’s functioning and mental, social, emotional or spiritual wellbeing.
There are three components within this: the event, the experience, and the effect. Events may be seen as traumatic; 1
Australian Catholic University, School of Nursing, Midwifery and Paramedicine, Melbourne, Australia 2 Sydney Local Health District, Mental Health Research, Sydney Australia 3 Monash University, Faculty of Medicine, Nursing and Health Sciences, Victoria, Australia 4 Parenting Research Centre, East Melbourne, Victoria, Australia 5 Australian Catholic University, School of Nursing, Midwifery and Paramedicine, Melbourne, Australia 6 NorthWestern Mental Health, Victoria, Australia Corresponding Author: Sophie Isobel, Mental Health Research, Sydney Local Health District, Sydney, Australia. Email:
[email protected]
2 individuals may have different experiences within events or circumstances; and there may or may not be lasting traumatic effects. Understandings of the pathways of transmission of psychological trauma between individuals, including transgenerationally within families, creates opportunities for prevention, early intervention, and treatment of trauma and its well-documented consequences. An ecological–transactional perspective of trauma highlights that individuals are affected by their environments and that maltreatment may occur between individuals but individuals are influenced by, and interact with, a wider macrosystem of ecological factors (Cyr, Michel, & Dumais, 2013), including poverty, homelessness, education, incarceration, drug use, health status, political or environmental disadvantage, ethnicity, gender, race, income, and class (Marmot, 2007). This is of importance when considering the scope and target of preventative strategies and in understanding the wider context within which familial relationships may be compromised. There is an urgent need for clarity of focus in language and understandings of psychological trauma that can be present within familial relationships. Within the varying theoretical constructs of psychological traumas, and distinct from the processes of psychiatric diagnosis, there is a need to refine the scope and definitions of psychological traumas that occur within familial relationships to ensure a cohesive evidence base and fidelity of the concept in application to clinical care. Greater clarity on the concept of psychological trauma will inform practice and research in the field through provision of a conceptual framework that can be used to guide practice and preventive interventions and as a basis for future investigation of psychological trauma and related interventions. Often referred to as relational or interpersonal traumas, in the literature, these conceptualizations of trauma also overlap with complex, intergenerational, betrayal, cumulative, attachment, and developmental traumas. Currently, different terms to refer to psychological trauma are used in different contexts, which can lead to the lack of clarity in practice and diffusion of the evidence base. There is a risk that the field of trauma will become problematically compartmentalized if the relationships and distinctions between terms are not overtly acknowledged. This review aims to explore the multiple theoretical concepts of psychological trauma as they are documented to occur within important familial relationships and to clarify similarities and variations on the concepts described in the literature for the purposes of consolidating the wider concept of psychological trauma and informing trauma-focused practice. This review fills a gap in the literature through analysis and synthesis of the concept of psychological trauma that can be used inform practice and future research.
Methodology A philosophical inquiry methodology of concept analysis was used. Concept analysis identifies unique characteristics of concepts, refines ambiguities, provides a deeper understanding of the attributes, and provides clarity of definition for researchers
TRAUMA, VIOLENCE, & ABUSE XX(X) (Liu, Avant, Aungsuroch, Zhang, & Jiang, 2014). This is a rigorous process by which an abstract concept is explored and clarified while also being differentiated from similar concepts to inform theory development (Walker & Avant, 2011). In this case, literature referring to any of the identified conceptualizations of interpersonal trauma were examined for the components of the concepts as defined by Walker and Avant: antecedents, defining characteristics and consequences. A concept is something conceived in the mind; a thought or a notion or an abstract or a generic idea generalized from particular instances (Merriam-Webster, 2016). A concept also becomes linguistic, as words are the mechanism for sharing the idea. Concepts represent aspects of reality and enhance the ability to communicate (Hanrahan, 2004); as such, the choice of words as well as their implied meaning(s) is important. The words used to describe the traumas are important mechanisms for communicating complex concepts and then become labels for experiences and effects.
Search Strategy The research team used initial scoping of the broad trauma literature to identify the key terms used to describe significant types of trauma occurring and transmitted in familial and attachment relationships. Identified descriptive terms paired with trauma were relational, interpersonal, intergenerational, developmental, betrayal, cumulative, attachment, and complex. These search terms were used to conduct a systematic search of the published literature within the PsycINFO database. Original research and discussion papers in the English language were included with no-date parameters so as to capture seminal and recent conceptualizations. The methodology of included papers was not an exclusion criterion, as the focus was on the paper’s contribution to definition of the concept. Initial culling was based on the specificity of the paper to a form of identified psychological trauma; papers focusing broadly on psychological or emotional trauma, those that focused only on Post Traumatic Stress Disorder or other diagnostic terms, those that referred only to a secondary source for definition, and unpublished manuscripts were excluded. Per the Walker and Avant (2011) approach to concept analysis, only papers that explicitly or referentially defined or detailed antecedents, defining characteristics and/or consequences of a specific form of trauma were included for data extraction. A data saturation method of extraction applied, with active searching ceasing once consistent definitions and components had emerged for each form of trauma (see Figure 1).
Analysis The main components of a Walker and Avant (2011) approach for concept analysis were used to guide analysis. This technique has been shown to be effective for identifying the unique characteristics of a concept and refining an operational definition (Hanrahan, 2004; Liu et al., 2014). Specifically, analysis focused on identification of the definition, antecedents, defining characteristics and consequences of relational, complex, interpersonal, intergenerational, developmental, betrayal, cumulative, and
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Trauma* n=274656 Psychological trauma OR Emotional trauma* n=17818 Limited to English language and academic journals
Interpersonal trauma* n=281
Attachment trauma* n=120
Intergeneration al trauma* n=66
Complex trauma* n=200
Betrayal trauma* n=70
Relational trauma* n=101
Developmental trauma* n=147
Screening via reading abstracts
Cumulative trauma* n=196
Articles excluded using exclusion/inclusion criteria n=899
Full text sourced and read for deinitions and components n=162
Articles excluded using exclusion/inclusion criteria n=100
Final articles included in review n=62
Figure 1. Search and screening.
attachment trauma. Verbatim descriptions of these components for any of the named traumas were placed in an Excel spreadsheet that was reviewed by the research team. All data were synthesized across papers to form descriptions of each identified trauma, their interactions, and points of difference. Emerging synthesized findings were discussed and compared by the researchers to ensure reliability. The contexts in which the terms were used were also considered to inform understanding of the concepts.
Findings Many papers not included in the final extraction referred to trauma without providing any description or definition, assuming an inferred meaning of the trauma to which they referred. Findings presented are extracted from 62 articles, based upon the Walker and Avant model. Consequences were extracted separately per the other constructs but later combined for all traumas as the overlap within the definitions, antecedents, and attributes of the traumas indicated that consequences could not be attributed to a single component. Findings are presented under four categories: definitions of trauma, antecedents of trauma, defining attributes of trauma, and consequences of trauma (see Table 1).
Table 1. Use of the Concept Analysis Model. Component
Walker and Avant (2011) Definition
Specific Definition in This Context
Events, incidents Events, incidents or or context that criteria that must come precipitate the prior to the concept in trauma phenomenon order for it to occur Defining Characteristics that name Characteristics of the trauma that identify it, attributes a specific phenomenon and those which and distinguish or distinguish it from differentiate it from a other traumas similar or related one Outcomes for the Consequences Events that occur as a individual as a direct result of the occurrence or indirect result of of the concept the trauma Antecedents
Definitions of Trauma The definitions of the conceptualizations of psychological trauma in the context of familial relationships are synthesized in Table 2.
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Table 2. Definitions of Trauma. Concept of Trauma
Synthesized Definition From the Literature
Interpersonal trauma Encompassing both the act and the effect of trauma; identified as traumatic injuries experienced due to threatening, uncontrollable and unexpected events caused by other people (Horowitz, 1986), usually a known and trusted individual such as a relative (Cohen, Hien, & Batchelder, 2008). “Events” encompass a range of acts of maltreatment, interpersonal violence, abuse, assault, and neglect experiences (D’Andrea, Ford, Stolbach, Spinazzola, & Van der Kolk, 2012) Relational trauma A subtle cumulative form of interpersonal trauma that particularly occurs within important attachment relationships and induces chronic unpredictable stress (Schore, 2001); not restricted to certain events but rather the effects of dynamics and circumstances upon individuals (Chong, 2015) Attachment trauma Based on attachment theory and the lifelong impacts of early attachment relationships (within the first two years) on the development of self and safety (Allen, 2013; Tassie, 2015); must occur within relationships where there is a close emotional bond and a significant degree of dependency, usually between an infant and primary caregiver, where the infant or child experiences the primary caregiver as abusive, neglectful or emotionally unavailable (Tassie, 2015). May also occur due to adoption, parental death or other disruptions within early childhood (Becker-Weidman, 2006) Betrayal trauma An effect of an event; based upon a theory developed by Freyd, who defined it as “trauma involving a sense of having been fundamentally cheated by another person” (Freyd, 1994, p. 308). More recently clarified as being perpetrated by someone close (Gobin & Freyd, 2014), as well as trusted or dependent (Platt & Freyd, 2015) and subsequently the distress level of the trauma is amplified by the impact on the developmental tasks of attachment and individuation (Martin, Cromer, DePrince, & Freyd, 2013). Often refers to intrafamilial sexual abuse (Gobin & Freyd, 2014) Cumulative trauma Several episodes of trauma exposure; sustained, repeated or multiple and commencing in the childhood years (Cloitre et al., 2009). Often involved a sequence of similar or dissimilar traumas that happen across the lifespan (Kira, Lewandowski, Somers, Yoon, & Chiod, 2012), with severity increasing with the number of different trauma types experienced, not the total number of traumatic incidents (Martin et al., 2013) and resulting in a complexity of presentation Developmental Makes an important distinction between the cause and the effect; identifying that the trauma is the lasting vulnerability as trauma a result of adverse relational experiences that occur within the first four years of life (Friend, 2012) or ongoing traumas occurring over several developmental periods (Bremness & Polzin, 2014) which impact on development. A theoretically driven construct, which refers to a potentially traumatic relationship between the child and caregivers that impacts development often through a disavowal of the child’s affective needs (Schimmenti, 2012) Complex trauma Refers to the effect that results from cumulative co-occurrence of different types of trauma typically beginning in childhood (Cohen et al., 2008); usually repeated or chronic (Aideuis, 2007) interpersonal events (Naff, 2014), most often perpetrated within the caregiving system or by other adults who typically are expected to be the source of security, protection, and stability (Courtois, 2004) Intergenerational The process by which elements of parental traumatic experiences are passed on to the children of the next generation trauma (Bradfield, 2011). It is debated whether the trauma that is transmitted is a replication of a parent’s trauma, a response to familial trauma or a predisposition or susceptibility to further trauma but may manifest as a unique entity in the offspring (Baranowsky, Young, Johnson-Dougles, Williams-Keeler, & McCarrey, 1998). Initially, was identified as a traumatic event that had ended but continued to affect later generations, however, now includes both historical, and at times continuing, traumatic experiences that affected more than one generation with understanding of the complexity in the causation, mechanism and effects of trauma impacting family members across generations (Schwerdtfeger & Goff, 2007)
Antecedents. Traumas occurring within familial relationships require a preexisting dependent relationship, frequently described as trusting or familial. Interpersonal trauma occurs between humans (Charuvastra & Cloitre, 2008) and violates or effects critical bonds with individuals. The act of violation can be traumatic, have a traumatic effect, or cause a lack of safety and subsequent vulnerability to trauma. The violation may occur in varying forms including maltreatment, violence, abuse, assault, and neglect experiences including familial physical, sexual, emotional abuse and incest, molestation; severe physical, medical, and emotional neglect; witnessing domestic violence as well as serious and pervasive disruptions in caregiving as a consequence of severe caregiver mental illness, substance abuse, criminal involvement, or abrupt separation or traumatic loss (D’Andrea, Ford, Stolbach, Spinazzola, & Van der Kolk, 2012). While many of these events would be considered traumatic, there are also a number
of suggested events that in a different context may have a less profound traumatic effect. These include the subduing of an individual’s affective needs by the demands, desires, conflicts, fears, or projections of another (Schimmenti, 2012) or cumulative and chronic unpredictable stress-inducing experiences (Schore, 2009). The antecedents to differing subsets of trauma are similar and overlapping; distinguishable by the subtleties of the relationships within which they occur and the individuals who participate in the relationships, rather than the acts of omission or commission themselves. Relational traumas specifically occur within an existing dependent relationship (Birrell & Freyd, 2006), usually caregiving and requiring an existing method of interaction within which the relationship is based. Often this may be characterized by conflicting signals, intrusive behaviors, role confusion, lack of soothing, withdrawing behaviors, or antagonistic behaviors (Amos, Furber, & Segal,
Isobel et al. 2011). Attachment trauma requires a dependent relationship with another human based on instinctual attachment where subsequently traumatic acts or events evoke extreme distress, fear, and other painful emotional states while undermining the development of the capacity to regulate emotional distress and trust in the intentions of all others (Alan, 2013; BeckerWeidman, 2006; Tassie, 2015). Similarly, in betrayal trauma, the relationship is dependent and critical built on trust which is critically violated (Platt & Freyd, 2015). Cumulative trauma may include any of these antecedents but requires the addition of similar or dissimilar alternate trauma-inducing events (Cloitre et al., 2009; Hodges et al., 2013), while developmental trauma is precipitated by all serious traumatic acts in the caregiving relationships that specifically affect development (Van der Kolk, 2005). Complex trauma relies on repeated and chronic exposure to maltreatment (Aideus, 2007; Naff, 2014) that evokes intensely negative affect including fear and feelings of powerlessness in a chaotic and stress-inducing environment (Lawson & Quinn, 2013) that does not support the development of age-appropriate flexible coping strategies (Bailey, Moran, & Pederson, 2007). Intergenerational trauma antecedents include the incapacity of the initial survivor of trauma (caregiver) to resolve the trauma (Connolly, 2011), subsequently then affecting the constant interchange between caregiver and child (Salberg, 2015). Defining attributes. Inherent to the violation of trusting, dependent or caregiving relationships are feelings of betrayal, shame, and guilt (Cohen, Hien, & Batchelder, 2008) with secondary maladaptive cognitions including self-blame (Alisic et al., 2014) and persistent beliefs about oneself as diminished, defeated, or worthless (Cloitre, Garvert, Brewin, Bryant, & Maercker, 2013). These beliefs can be conscious or more inherently embedded into the construction of self (Schore, 2002, 2009). As crucial familial attachment relationships are the first experiences of trusting other humans, traumatic experiences shatter assumptions of safety and trust (Alisic et al., 2014; Charuvastra & Cloitre, 2008) and alter the sense of self in relation to others (Bremness & Polzin, 2014; Schore, 2002). The violation of basic assumptions of safety in these relationships and the conflicting dependency of the trauma recipient can be marked by dissociation and fragmentation (Birrell & Freyd, 2006), as primitive regulatory defenses against insoluble fear associated with activation of conflicting systems of attachment and defense (Amos et al., 2011; Martin et al., 2013; Schore, 2002). Dissociation in its many forms may become necessary for survival (Platt & Freyd, 2015), while activation of the neurobiological mechanisms of equilibrium maintenance simultaneously impact longer term mental health and physical wellness (Naff, 2014). Relationship-based traumas are characterized by the dual problem of exposure to traumatic events or effects and the impact of this on immediate and longer term outcomes (Becker-Weidman, 2009). Distinct from the other subsets, cumulative trauma has defining attributes of multiple co-occurring complex symptoms experienced simultaneously
5 (Cloitre et al., 2009) and requires core traumas, triggering traumas and peripheral traumas (Kira, Fawzi, & Fawzi, 2013) adding to symptom and assessment complexity (Hodges et al., 2013). Developmental trauma requires a disruption of the stability and continuity that is required for normative development (Reviere & Bakeman, 2001) and that interferes with neurobiological development, particularly the capacity to integrate sensory, emotional, and cognitive information into a cohesive whole (van der Kolk, 2005). Complex trauma is distinguished by lifelong disturbances of self-organization (Lawson & Quinn, 2013), particularly in relation to responding to, displaying, and regulating strong emotions (Cloitre et al., 2013). Intergenerational trauma can be observed with a blurring of self and other where the representations of trauma experienced by the important other become incorporated into the self of the recipient (Bradfield, 2013). Intergenerational trauma is less a discrete event or dynamic and rather an antecedent itself to traumatic attachment (Salberg, 2015) and disrupted construction of self and identity (Connolly, 2011). All familial traumas have attributes related to disruption of intersubjective constructions of self. Consequences. The consequences of exposure to any of these forms of interpersonal trauma within familial relationships are varied; however, when exposure occurs or commences within childhood, the consequences can be profound and lifelong. Consequences include neurobiological changes in the brain, comorbidities, risk of pathology, vulnerabilities to further harm, interpersonal and intrapersonal difficulties, and internalized formulations of self and other. Across the conceptualizations, consequences refer to broad and specific disruptions to critical attachment processes including the implications of a confounding drive to attach to someone also perpetrating harm; risk of dissociation; lack of, or altered, concept of “self”; and dysregulation of affect and transgenerational vulnerabilities. All interpersonal traumas have been reported to result in higher rates of mental health diagnosis than environmental traumas and to have significant correlates including difficulty recovering or modulating distress, isolating from conflict, impaired ability to form or benefit from a social network, and interpretation of supportive efforts of others as hostile (Charuvastra & Cloitre, 2008). Logically, a lack of trust in interpersonal relationships can affect daily functioning (Alisic et al., 2014). Psychological symptoms of trauma have been linked to biological correlates and abnormalities (D’Andrea et al., 2012), suggesting the embedded nature of such difficulties within the person’s experience of self. “Chronically traumatized individuals feel shame not only for what has happened to them, but for who they are” (Dorahy et al., 2013, p. 73). Schore (2001, 2002, 2009) identifies the effects of early relational interactions upon the right brain and the subsequent effects of early trauma, suggesting that caregiver-induced trauma is “qualitatively and quantitatively more potentially psychopathogenic than any other social or physical stressor” (2001, p. 207). He notes that the most significant consequence of early relational trauma is the lack of capacity for emotional
6 self-regulation and reports that affect dysregulation is now seen to be a fundamental mechanism of all psychiatric disorders (2002). Neurobiological alterations associated with childhood trauma are wide and varied but include significant alterations in the developing right brain, the hippocampus, the amygdala, the prefrontal cortex, the hypothalamic–pituitary axis, the concentrations of corticotrophin releasing hormone, and the noradrenergic system (Schimmenti & Caretti, 2014).
Discussion While psychological traumas occurring in important familial relationships are widely recognized to be significant, differing descriptions and conceptualizations of these traumas add complexity to the field of psychological trauma knowledge and its application to practice. When members of differing disciplines, fields, or groups use the same or similar words with subtle or major conceptual differences in interpretation, misunderstanding or dissent can occur as well as slow evolution of divergent evidence and philosophical bases (Bonis, 2013). This can hinder collaboration and disrupt the translation of knowledge into effective practice. Distinctions between trauma terms reflect the differing purposes and intents for which each term was originally developed and may also be related to their discipline of origin. Interpersonal trauma is a broad descriptive term often used in nonacademic literature and in health policy documents to delineate from environmental traumas (D’Andrea et al., 2012). Complex trauma and Developmental trauma were developed by psychiatrists as outcome-based descriptors (Herman, 1992; Van der Kolk, 2005) with associated disorders, in an attempt to have the profound effects of sustained interpersonal trauma recognized by mainstream diagnostics and reduce ineffective overdiagnosis and treatment. Psychodynamic descriptors of trauma that capture the relationship-based experience, such as betrayal trauma and relational trauma, identify that relationships are reciprocal experiences between individuals, within which conscious and subconscious experiences manifest (Bradfield, 2011) with bidirectional impacts. Intersubjectivity, which occurs within these important attachment relationships, results in each participant’s reflection of self in the experience of the other affecting their perception of self (Becker Weidman & Hughes, 2008) and indicates how trauma can occur within relationships and not be limited to individuals (Bradfield, 2011). Traumatic acts and dynamics occurring in the intersubjective space of attachment relationships can crucially affect trust and safety but also affect the construction of self. Relational trauma is a widely used term, more recently emphasized in the field of psychology by Schore (2002) in his significant work to link attachment, trauma and neurobiology through detailed exploration of the role of the right brain and the construction of self. The word “relational” is used specifically to emphasize the sustained and cumulative social nature of the interactions within which the trauma occurs. Betrayal trauma was defined by Freyd (1994) to emphasize the
TRAUMA, VIOLENCE, & ABUSE XX(X) role of dissociation in maintaining inescapable traumatic bonds and to propose betrayal as an alternative primary indicator of trauma to the “fear and terror” often referred to in other definitions (Freyd, 1996). Attachment trauma references the substantial field of attachment theory based on the work of John Bowlby and Mary Ainsworth. Bowlby was a psychologist, psychiatrist, and psychoanalyst (Bretherton, 1992), a fact that may have some relevance to the wide acceptance and use of his work across fields and disciplines. His work on the bond between infant and caregiver was based on evolutionary biology and ethology (Fitton, 2012), operationalized by Ainsworth, a psychologist, who developed a replicable test making the theory measurable and practical. Intergenerational trauma has been a socially identified concept emerging from historical and cultural traumas experienced by indigenous populations across the world and from the sustained transgenerational effects of Holocaust trauma. Descriptions of “secondary traumas” were widened to intergenerational trauma when the effects of the Holocaust were proven to still be of impact in the thirdgeneration post-Holocaust in Jewish populations (Kellerman, 2001) and up to six generations post-colonization in indigenous populations (Atkinson, 2002). These sociocultural fields were identifying similar patterns of transmission to those identified by Fraiberg (a psychoanalyst) in her seminal work “Ghosts in the nursery” (Fraiberg, Adelson, & Shapiro, 1975) which detailed transgenerational patterns of interaction observed with socially disadvantaged mothers and their infants, work which has remained of psychoanalytic relevance. Cumulative trauma, however, was most recently created as a broad statistical marker term for complex trauma or developmental trauma (Hodges et al., 2013). While theoretical or descriptive descriptions of trauma have been proposed to decrease clinical utility by lacking clarity and translation to practice (Connolly, 2011), medical and diagnostic approaches to trauma which attempt to define the precursors or specify the neural pathways of harm may risk simplifying the subtle effects of dynamics or events upon the person, their life and their experiences. While there remains a need for both theoretical and medical descriptions of trauma, and for adjustment of concept and language to suit professional disciplines, domains, and intended purpose, any professional territorialism of domain by disciplines should ensure that the wider field is not disadvantaged by attempts to define constructs and that understanding of the significant overlap and shared terrain is of importance to minimize the compartmentalization of the evidence base and conflicting clinical interpretations of the terms. While primarily informing the research fields of trauma, concept clarification may also impact clinical practice. Ongoing debates about the diagnostics of trauma, increasing awareness of efficacy of trauma-specific interventions, and implementation of systemic trauma-informed approaches to service delivery may all benefit from less conceptual ambiguity and clarification of terminology. In reaction to growing evidence of the relationship of trauma with health and treatment, many clinical services have begun to move toward being “trauma informed” to deliver care informed by knowledge of
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Intergeneraonal trauma
Interpersonal Traumas occurring within familial/aachment relaonships
Aachment trauma
Cumulave trauma
Betrayal trauma
Complex trauma
Relaonal trauma
Developmental trauma
Intergeneraonal trauma
Figure 2. Interactions of conceptualizations of psychological traumas. Unidirectional arrows indicate potential for progression from antecedent to consequence. Bidirectional arrows indicate potential for shared cause and effect or composite characteristics. Simple lines indicate potential subgroups of a larger descriptive term.
the prevalence and impact of trauma on individuals, including their health and treatment (SAMHAA, 2014). As linguistics around trauma once again become part of the predominant discourse in clinical domains, conceptual clarity and increased understanding of the pathways and implications of transmission of trauma between individuals may aid in ensuring that implementation is effectively targeted and does not lack specificity to the subtle differences in the way trauma can develop and manifest. Concept clarification will also aid in ensuring that although the term trauma may continue to be used in different contexts with slightly differing connotations, compartmentalization of the wider evidence base does not impede the development of appropriate preventative strategies and interventions to improve outcomes for families. From this analysis, there may be no clear correct term or widely relevant definition of psychological trauma, but an understanding of the interactions between varying concepts of trauma is required for communication and shared understandings, and to inform effective practice and future research.
Interaction of Traumas This analysis identified that interpersonal traumas are distinguished from traumas not occurring in the context of relationships with other humans. Within interpersonal traumas, those that occur within trusted or dependent relationships may be attachment traumas, betrayal traumas, and/or relational traumas; betrayal traumas are more likely to be traumatic acts
perpetrated by a caregiver or trusted other, while relational traumas may be traumatic dynamics present in the relationship itself. Attachment trauma is a form of, as well as an antecedent to, relational trauma and developmental trauma; a component of, and an outcome of, betrayal trauma; and a common predictor of cumulative trauma. When any of these forms of interpersonal traumas occur in infancy or childhood, they may cause developmental trauma that affects physical and psychological development. In adulthood, the outcome of relational traumas, betrayal traumas, attachment traumas, or interpersonal traumas may be recognizable as complex trauma rather than developmental. Multiple and varied traumas of these kinds, and others, may cause cumulative trauma, identifiable by its contradicting or parallel trauma reactions within a single individual. Any trauma passed on directly or indirectly across generations may be intergenerational trauma; both an exposure and vulnerability transmitted relationally (see Figure 2). These interactions may be useful for practitioners in understanding the types of trauma their clients have experienced across the life span, the overlap of descriptive terms dependent upon context and that more than one form of trauma may coexist. Preventive interventions need to accommodate the variations in trauma type in order to most effectively interrupt the transmission of traumas within families and beyond. Currently, there is fragmentation of “islands of researchers who may not collaborate or integrate with each other” in the field of trauma (D’Andrea et al., 2012, p. 188), a situation potentially amplified by compartmentalization of the concept. There is, however, acknowledgement of significant overlap in
8 terms as identified in this concept analysis. Birrell and Freyd refer to “betrayal/relational traumas” (2006); Cloitre et al. refer to cumulative trauma as a form of complex trauma based on developmental knowledge (2009); Cohen, Hien, and Batchelder (2008) describe cumulative trauma as consistent with complex trauma; and Becker-Weidman (2009) uses the terms complex trauma and developmental trauma interchangeably. Schimmenti (2012) identifies that all constructs of childhood trauma highlight the accumulation of difficulties that derive from external pressures upon a child to maintain defenses against overwhelming anxiety, which itself becomes traumatic, and Schore (2002) describes in detail how a traumatized early relationship may override any genetic, constitutional, social, or psychological resilience factors and that the ensuing adverse effects on brain development and alterations in the biological stress systems may be regarded as “an environmentally induced complex developmental disorder” (p. 9). Nearly, all discussions of the effects of intrafamiliar trauma across the life span refer to the critical role of attachment in buffering, protecting from, not protecting from, repairing, causing vulnerability to, directly causing, or contributing, to trauma. While clarifying the multiple definitions of trauma is important for consistency, there are risks involved in clarifying the overall concept of trauma. There may be a “need for greater flexibility in terms of how trauma is defined and treated” (Naff, 2014, p. 79); yet conflictingly, there is a need to not widen the definition so far that it becomes generic and lacks significance: “Given the conceptual bracket creep in the definition of trauma, an increasing number of life events are now deemed to qualify as traumatic stressors . . . We are all trauma survivors now, or so it seems” (McNally, 2007, p. 280). There may also be risk of further pathologizing individuals rather than environments (D’Andrea et al., 2012), distracting from social responsibilities to ensure safety and protection. Whenever trauma is analyzed thoroughly, and particularly when the family unit is the context, there is a risk of blaming parents and specifically mothers. A number of papers in this review overtly and less overtly labeled mothers as the source of trauma; either directly as the traumatic attachment figure or through failing to maintain their expected attachment role of protection from other instigators of trauma. This is reminiscent of early family work in mental health care which blamed parents, particularly mothers, for mental illness (Goldman, 1982). Returning to an ecological perspective of parenting may aid in emphasizing the social and political implications of caregiving, attachment, and intergenerational trauma through the enactment of social policies that promote trauma prevention and attachment promotion for all caregivers. Familial trauma may be best understood as a psychosocial phenomenon composed of interactions between risk and protective factors at personal, relationships, community, and societal levels of ecology (Cyr et al., 2013). Subsequently, reduction in inequity in social and health policy may lead to increased access to the resources required to parent effectively, but this requires multilevel social and collective action beyond targeting individuals (Marmot, 2007). With research indicating the significant burdens of trauma on
TRAUMA, VIOLENCE, & ABUSE XX(X) health-care environments across the life span and health domains (Felitti & Anda, 2010), the question is raised of what social structures are required to support trauma prevention and healthy familial attachments as a public health priority.
Conclusion Attempts to define trauma assume that a unitary concept exists and that the use of the word is associated with its correct definition. Philosopher Wittgenstein (Wittgenstein & Anscombe, 1958) argued that words are not defined by that to which they refer or represent, but their meaning is in their use. The word “trauma” is used in multiple ways, with definitions and scope often implicit or implied, to encompass overlapping assumptions about events and effects within an individual. Components of the concept of trauma occurring in important human relationships have overlapping attributes, antecedents and consequences, and very few clear defining features. Specifically, defining the implied meaning of references to trauma at their point of usage both academically and clinically may aid in clarifying confusion. Research in the field stems from a variety of purposes and intents; antecedents, defining attributes, and consequences are all entwined depending on whether the trauma is viewed as the event, the effect or the consequences; and definitions of differing subsets significantly overlap. Clarity of relationship between components is useful in ensuring linguistic consistency in consolidating the evidence base and progressing clinical and community awareness. This review has found that documented concepts of psychological trauma occurring within familial relationships are not exclusive of each other but encompass events and circumstances as well as their short-term and long-term effects on individuals. These traumas develop and are transmitted in the space between people, both purposefully and incidentally, and have particularly profound impacts when they stem directly from primary attachment relationships in infancy. The transmission of trauma between individuals, including intergenerationally, provides opportunities for targeted prevention and intervention. Linguistic and conceptual clarity as presented is paramount to ensuring specificity of trauma-focused intervention and cohesive progression in the field of trauma-related research. Acknowledgment The authors wish to acknowledge the contribution of Dr. Danny Hills to early versions of this article.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research is supported by an Australian Government Research Training Program Scholarship.
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11 Author Biographies Sophie Isobel, RN, Grad Cert CAMH, CFN, Res. Meths., is a clinical nurse consultant for quality, ethics, and research in Sydney Local Health District in Australia, where she undertakes research in mental health service improvement including the introduction of trauma informed care. She is undertaking a PhD through ACU in Melbourne using qualitative methods to explore intergenerational trauma in families, where a parent has a mental illness. Melinda Goodyear, PhD, is a research fellow at Monash University and a senior implementation specialist at the Parenting Research Centre. She has been actively researching the impact of mental illness in families for over 15 years and now works with government and nongovernment organizations to promote evidence-based practice for vulnerable families. Kim Foster, RN, PhD, is a professor of mental health nursing at Northwestern Mental Health, Melbourne Health, and Australian Catholic University, where she heads the Mental Health Nursing Research Unit based at the Royal Melbourne Hospital. She conducts mental health and psychosocial research with children, young people, and families on issues including prevention of intergenerational mental illness and improving well-being and resilience for vulnerable families.
