Transcript for
Unravelling intergenerational trauma

Runtime 00:31:30
Released 26/8/19

Narrator [00:00:02] Welcome to the Emerging Minds podcast.

Sophie Guy [00:00:08] You’re with Sophie Guy, and today I’m joined by Jackie Amos, a child and adolescent psychiatrist, for a discussion about intergenerational trauma and ways of working with severely distressed families. Jackie currently works with Centacare’s family reunification and preservation teams in South Australia, where she trains and support staff in parallel parent and child therapy, an intensive attachment and trauma focussed therapy that individually supports the mother and child as well as their relationship.

Sophie Guy [00:00:37] Thank you, Jackie, very much for joining me today.

Jackie Amos [00:00:39] Thank you for inviting me.

Sophie Guy [00:00:41] I guess to start with, it would be good to hear a bit about your background, including a little bit about your doctoral research.

Jackie Amos [00:00:49] Sure. My interest in this area really started a long way back in my psychiatric training when I did my child and adolescent experience rotation, but also working with young people who were diagnosed with borderline personality disorder. And at the same time, I was training in Gestalt psychotherapy, and began to see people for long term psychotherapy and realised that a lot of the people I was seeing were talking about difficulties that came from early in their lives. And so I got really interested in pursuing that kind of idea in all sorts of different ways and eventually became a child and adolescent psychiatrist with the hope of kind of interrupting family patterns that were distressing for all family members to see if that would improve outcomes for young people.

Jackie Amos [00:01:49] And it was in the process of doing that work and starting to question how could we both support parents who were clearly struggling with their own histories to be able to work constructively with their children, who were also struggling with emotional and behavioural issues without losing the focus on the child. And it was in trying to answer that question that I first came across my PhD supervisor and she invited me to come and do a PhD with her. And we spent the time of my PhD trying to investigate how mothers found themselves in a predicament where they deeply loved their children, but struggled to be the parent they wanted to be, and kind of what the impact on the child was. And how by understanding the pathways by which the relationship gets to the place that it gets to could we identify the points where you could disrupt those pathways and promote healing.

Jackie Amos [00:02:55] There’s a lot of interesting research, research that had been going along on its own lines. And what we wanted to do was see if we could pull the whole of that research together into a model that not only made sense, theoretically and made sense academically, but that we could directly translate into, what do you need to do on the ground to make a difference for these families.

Sophie Guy [00:03:21] And for listeners who are not familiar with your PhD research could you talk a little bit about the model that you’re referring to?

Jackie Amos [00:03:29] Sure. So we build the model in stages and so it’s probably easier to talk about a little bit in stages. But essentially we built two complementary models which we later brought together in a single model. And what we did was we chose an overarching framework, which was attachment theory, which led us to choose kind of evolutionary theory, or evolutionary theoretically inspired research to try and get some consistency in the model.

Jackie Amos [00:04:03] And then what we tried to do was sort of plot a lifecycle model of a parent, a child, or an infant who grows up to become a mother and has her own baby and how having a baby can impact that mother. So we started out with the mother as infant and we had a look at what can happen if somebody through things outside of their control, doesn’t receive the care, optimal care as an infant. So we looked to attachment theory and looked at mainly disorganised attachment and took the idea that that infant can be exposed to fright without solution when a mother is unable to tend to her infant’s needs because of her own trauma. But also we added some ideas to that, that perhaps this infant is also subject to shame, most particularly when an infant reaches out to connect with a mother with excitement or joy or love, and that mother is unable to respond for whatever reason. And that infant experience is not being met kind of in their uniqueness and treasured, cherished.

Jackie Amos [00:05:24] What we hypothesised is that this wound, which we call the primary relational wound, sits at the core of a lot of the intergenerational difficulties that we see where relationships in multiple generations are distressing for both parties. And we then kind of said, well, if that sits at the core, what happens next as this infant begins to develop? And so drawing quite a lot on the work of Giovanni Liotti, we suggested that this infant tries all sorts of strategies to manage this shame and fear without solution. We said that mainly these would be individualistic, anti- predator defensive strategies. So things like fight or flight or freeze or trying to avoid the parent and realise that a lot of those strategies would be ineffective when the infant is kind of dependent on the mother for survival. And that became one of the big questions to answer. How do you stabilise distress in a relationship where both members need to be together and want to be together?

Jackie Amos [00:06:41] So we drew on the theories of structural dissociation of the personality and suggested that the kind of fear and shame without solution and the sort of ineffective defences get sort of pushed off to the side and away from the rest of the developing personality. And so the personality becomes split between the sort of other aspects of the person that begin that continue to develop and the attachment aspects which get kind of pushed away to the side. But that then can be reactivated or brought back into consciousness by certain circumstances. And that left us with another question, which was, well, if that gets pushed off to the side, how then does this dyad manage over the long term? Because that’s quite an unstable solution. Whenever that mother and child encounter further stressful situations, the attachment system’s re-activated and all of the kind of chaos that comes with fear and shame without solution and all the efforts to manage that that are ineffective kind of flood consciousness. And we’re suggesting that that’s an extremely distressing, unmanageable state that’s not really experienced in words and pictures as a memory, but is experienced as a flood of physical and somatic and emotional sensations that kind of don’t have a context. And so when that happens, that infant or that mother or both don’t understand that this is the reactivation of a memory. And they kind of think that the problem lies within their relationship and that for the mother, the infant is the source of distress. And so she tries to act on the infant. And in the process of acting on the infant in kind of desperate defensive ways, stabilises her own internal state. And I’ve kind of jumped now from mother as infant to the mother having that early infancy trauma re-activated by her infant.

Jackie Amos [00:08:55] But there’s kind of a bit in the middle that I’ve missed out that I’ll kind of go back to now, because if that’s the state that’s happ- that’s happening in the mother-child relationship and there’s this constant risk of reactivation of trauma and stabilisation in that kind of desperate way, which might well look like acute maltreatment, then there’s got to be another solution that stabilises that unstable state. So we kind of got a model that’s got a primary relational wound in the middle, at the beginning. And we’ve got this kind of unstable stabilisation of the structural dissociation but that can be reactivated. And we thought, well, there’s something else must happen here because that feels too unstable to be a lasting or enduring solution. So we went back to the literature and there’s a lot of observational research in the literature which suggests that children around the age of five or six in disorganising relationships with a parent will often develop what are called controlling hostile-punitive or controlling caregiving strategies. And there’s also research that shows that adults who’ve come from those backgrounds can develop states of mind that are separated but kind of exist alongside each other that are hostile or helpless. And that research looked compelling in terms of maybe this is the description of the solution. But what we couldn’t find was a good explanation as to why that might be the solution.

Jackie Amos [00:10:35] So we went back to the evolutionary theory literature and we discovered the work of Michael Chance who talked about two different types of social styles or modes of interacting that can occur in nature. And they were called agonic mode and hedonic mode. And what caught our attention was in his description of agonic mode, he was talking about dominance and submission hierarchies being a way to stabilise group relationships where resources were in short supply. And we thought hmm. We wondered if that could be a good explanation for these controlling hostile-punitive and controlling caregiving or hostile and helpless states of mind that were in the observational research. And so we kind of added a layer to our research where we are suggesting that kind of dominance and submission hierarchies and appeasement become the way of stabilising the parent-child relationship. And the way they do that is by prescribing rigid roles, which increases predictability when kind of safety and togetherness and love are in short supply. So that was kind of the final stage of the model. And that set the scene for kind of thinking about, so what did that mean about treatment.

Sophie Guy [00:12:04] Perhaps we will go from there and maybe we need to come back to talk about the treatment but perhaps you could talk a little bit now about the work you’re currently doing with Centacare and how this model that you’ve developed and your research is informing that work.

Jackie Amos [00:12:21] Sure. Yeah. I’m currently working in the Children’s Services Unit in Centacare in South Australia. My role there is as a consultant to the teams who are working with families who’ve come to the attention of the child protection, the Department of Child Protection. So we have a early intervention services, we have family preservation services, we have reunification services. We provide help for parents who are struggling with drug use issues. And we also have a re-, specialist reunification foster care program. Currently, I work clinically on the reunification program. And I guess one of the impacts that this model has had on our orientation to intervention with the families is for us to have a look at the existing case management process and see whether we can build into it an increased focus on trying to address the trauma triggers for the parent and the parent’s trauma history in the hope that we can prevent some of the hostile kind of helpless patterns or the activations of acute kind of trauma, the primary relational wound that we think are interfering often with parenting. But we’ve also been thinking about when we bring the parent and child back together, how we help them to understand each other and how we help them to understand how they’ve become triggers for each other’s trauma as a way of trying to build in some really sustained change for the family so that they can, in fact, go on into the future kind of reunited and have those relationships endure. So we’ve been trying to add a sort of trauma layer to the existing case management processes.

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Narrator [00:14:21] You’re listening to an Emerging Minds podcast.

Sophie Guy [00:14:27] Yeah I’d just like to pick up that idea about how you use the ideas around the primal relational wound and. Because my understanding is that, and we haven’t really gone into this yet, but that you have used a therapeutic approach approach called ‘parallel parent and child therapy’, and that typically that’s quite long term therapy. So I’m just wondering how that how you’re able to integrate that into the work you do at Centacare and how does that go and how successful is it, taking something that’s probably quite sustained and needs to be when I say long term, maybe up to a couple of years. How does that go feeding that into the work and how successful is that?

Jackie Amos [00:15:12] Going back to the sort of treatment we used the theoretical model to predict objectives of treatment so that instead of kind of people needing to apply a particular therapeutic intervention, what we could have a look at instead was what the objectives of treatment should be so that people could meet them in any way that they could show kind of met the objectives. And the objectives really are firstly to identify and work with that kind of implicitly encoded emotional memory. So address that trauma, bring it into consciousness, find words for it and bring it into a story to kind of process that trauma. And the second major objective is to try to get the mothers and children or fathers and children to rely less heavily on that agonic mode, the dominance and submission hierarchies, and move into the hedonic mode, which is a sort of co-operative way of relating, which is based on safety and togetherness. And that has some components which are kind of helping the parents and children develop a sense of kind of being different from each other, but connected. So we’ve referred to that as having a differentiated sense of self with agency. And also managing shame.

Jackie Amos [00:16:49] The reason I bring that up here is that in my PhD one of the ideas we put forward was that one of the most powerful ways to move families into hedonic mode is actually to immerse them in a hedonic relational context. And so one of the things that was already present in Centacare but that we’ve been working on intentionally doing is creating really rigorously co-operative relationships with all of our families, and kind of really embedding treatment in that hedonic framework. So that involves things like transparency, being really clear about roles, responsibilities, our reporting relationships with departments. Being really clear that our intention is to cooperate and get along side the family, to understand things from their perspective, to try to work to develop all the strengths that they have and to come from a place of respect and genuine dialogue with them. And we’ve been intentionally really focussing on doing that because our staff have the capacity to spend a reasonable amount of time with families each week. So by embedding the family in that kind of co-operative relational matrix, if you like, a whole big chunk of the therapy is already happening.

Jackie Amos [00:18:19] And then what we’ve added to that is for families who are interested, we’ve added to that these are the two components. So one of them is that adult exploration of attachment interview where we would sit with a parent and explore how their experiences of being parented have influenced their parenting. And we do that using a process developed by a woman called Heather Chambers, where we ask two seemingly quite, well we do, what we do first is construct a genogram of the parents, kind of family, with them as the child. And we identify any caregivers who’ve been significant throughout early childhood right through teen years. And then we would sort of draw what we call an inheritance map of that parent’s experiences. And we do that by sort of sitting with a large piece of paper and dividing it down the middle and putting a couple of questions at the top of each column. So one is, what did you learn from your caregiver about being a parent. And what did you learn from your caregiver, whichever one, about being a child. And then we explore the stories they know from their childhood, things I’ve been told, things they remember. Anything at all that comes to mind for them. And we try to pull out of that statements about what it means to be a parent and what it means to be a child. and we end up with a kind of set of maps that help them, parents to see that they are kind of struggling to change inter-generational patterns and to change things that they’ve been given in a kind of non-verbal sense right from early in life. And it just allows a bit more choice around those things. But also being confronted with that in words helps people to start to process any trauma that exists kind of in those stories.

Jackie Amos [00:20:23] And the second aspect that we are beginning to use in the program is called ‘Parallel Parent Child Narrative’. And the purpose of that process is to sort of take a history of the parent-child relationship but in a therapeutic way. So we’re kind of slowing down the process of history taking and spending a lot of time making sense of how people have experienced the relationship. What emotional meanings they’ve attached to events in the relationship. How past might have intruded on an understanding of an event in the present. But most importantly, looking for the good intentions behind any actions or any distress to see if we can move people away from sort of blaming each other or blaming themselves. We kind of think about blame as or kind of, existing beliefs as understandable mistakes of meaning, but understandable in the context. And then we spend a lot of time looking for the good intentions behind any actions so that we can really show people that what has happened is nobody’s fault, but that it’s really, really sad. And help kind of move from a place where hurts and traumas are the central narrative of their relationship to a new story of the intention to care and connect that’s been disrupted by circumstance or context. And part of that context is the internal context that the mother brings to parenting or the father brings to parenting. But also our families have often been surrounded by adversity in their external world, too. So helping people to kind of just put the difficulties in their relationship into the broadest possible context. One of those contexts being that nobody sets out to be a terrible parent or to hurt their child or to do anything that, you know, repeats a past that they’ve found to be painful. But because a lot of what we’ve talked about, I’m not sure I really emphasised this at the beginning is trauma that’s not accessible to memory, that’s pre-verbal. That’s kind of hard to name and identify and label this sort of implicitly encoded trauma. What we’re trying to do is kind of get it back and show people that this is not a blame issue. It’s an issue of forces that are in operation in the context. So that they can take a new story into the future.

Sophie Guy [00:23:12] Okay. In reading a little bit and familiarising myself with your work and the idea of relational trauma, it sounds to me as though that could almost explain a lot of emotional behavioural problems. And I’m just wondering, how is relational trauma similar or different to what we might call emotional behavioural problems in kids?

Jackie Amos [00:23:37] So emotional difficulties might in fact be being driven by anxieties that come from that early trauma or shame. And when someone’s flooded with those feelings and they don’t have a kind of established or constructive way to deal with them, then that can result in things like aggression, which can get labelled as a disorder. Or a child who’s constantly battling anxiety and fear related to trauma that’s occurred in a relationship so, which is triggered by the experience of relationship can look disorganized and chaotic and a bit ADHD. And it’s not to say that there isn’t such a thing as ADHD, it’s just to say that as research continues to build in this area, we have to ask a question as to whether what this child might be experiencing is the effects of relational trauma or is it something else. So things like if a child becomes distressed or an infant becomes distressed, the parent becoming distressed as well, instead of being able to soothe the infant. Or dismissing the infants distress or mocking or teasing or kind of both wanting to soothe but being frightened of the infant. So they can be quite subtle things. But it’s the accumulation of many, many moments of kind of mismatch that that can lead to this kind of fear and shame that hasn’t been able to be managed or regulated or understood or given words. So yeah, it’s about kind of saying there’s there’s possibly for some children, something else going on here and that it’s the experience of being in relationship with others that is triggering. And if we can understand that, then we can approach the children differently.

Sophie Guy [00:25:42] And I also wonder, because we’re talking about highly, in your work anyway I suppose, highly distressed examples, I suppose. And it seems to me as though this pattern, this can can be going on in more and more diluted levels to explain a lot of, you know, less severe or maybe more simple anxiety or emotional behavioural problems or mental illness. What do you think about that?

Jackie Amos [00:26:10] Yeah, look, certainly having thought a lot about this in a different setting initially, in a CAMHS setting, but also working with some colleagues who use this model in private practice, that certainly a lot of these insecurities occur in more diluted forms in other families. And in particular, sort of rather than focussing totally on the disorganised attachment, there can be the more organised but anxiety provoking forms of attachment. And certainly my colleagues, particularly who work in private practice are finding that by thinking about families in this way and addressing that layer and changing the relationship, then a lot of the behaviours and emotional difficulties in both parent and child are being addressed. And, you know, this is this is just one of a whole lot of developing approaches to working with relationships. I think what I like about it is we’ve got that kind of really robust theoretical model sitting underneath it. So it gives us a really good sense of why we’re trying to do what we do. But I think there’s quite a move in the field generally to thinking about working with relationships. We’re social creatures. Relationships are really central to our development and our well-being throughout life. So it seems that the more we understand that, the more clinical approaches are following that path and trying to work in that way.

Sophie Guy [00:27:52] Is there anything that you would like to add to this conversation that I haven’t asked you directly in questions? Is there anything else you’d like to say?

Jackie Amos [00:28:02] One of the things that I think is really central to the work we’ve been developing that we did talk about, but that’s quite important to emphasise is, particularly in the child protection space. I think that there has been a tendency to work punitively with parents who’ve abused their children. I think it’s something that people find difficult. And and I think one of the things that is most important about the implications of the work that we’ve developed is that there’s no space for responding punitively to someone whose capacity to parent is being upended by their own experiences of trauma. And so it has given us a very solid theoretical reason for working with the utmost kindness and compassion, not just with the children who obviously need that too, but also to extend that to the parents. I think sometimes when we talk about putting the child at the centre or being child focussed, we can make it that it’s either the child or the parent. And that, I think, is an understandable mistake, but not a helpful one. It kind of moves us into that agonic dominance and submission frame of working, because we’re then saying the child has to be primary, therefore the parent can’t be. And I think what this model suggests is that we need to sit in a really hedonic place where we say the child is central and if we’re going to heal this child’s life, then we need to think about the parent and they need to be also central in our thinking. The child’s right to safety always comes first. But if we are looking to give children back to their parents, if we’re not also thinking about the parent in the same kind and compassionate way, we’re unlikely to provide the support for the parent that will bring them to a place where they can be effective parents for their children. So in an indirect way that is still keeping the child at the centre.

Sophie Guy [00:30:27] Well I feel, I find this so fascinating. I could keep talking. Thank you so much, Jackie. It was really great. I enjoyed that conversation and thank you for coming in.

Jackie Amos [00:30:38] It’s a pleasure.

Narrator [00:30:40] Visit our website at www.emergingminds.com.au to access a range of resources to assist your practice. Brought to you by the National Workforce Centre for Child Mental Health, led by Emerging Minds. The National Workforce Centre for Child Mental Health is funded by the Australian Government Department of Health under the National Support for Child and Youth Mental Health Program.