by Mary Romm, Licensed Professional Counselor in Gloucester, VA

The Scoop on Parent-Child Interaction Therapy

Are these some of the thoughts inside your head?

“My child is out of control.”

“I don’t enjoy spending time with my kid anymore.”

“My kid hits/bites/kicks me.” 

“Another daycare kicked my child out today.”

Are you ready for help? 

Who PCIT Can Help

As a therapist, I’ve utilized Parent-Child Interaction Therapy (PCIT) to help children ages 2-7 who have extreme behavioral challenges and seen them learn to listen and behave. I’ve used PCIT in my work with kids who had to wear a monitoring bracelet because they ran away so much, broke mirrors in a rage, and used the shards to carve up furniture, or parents were ready to commit them. Those same kids then listened to their parents, no longer engaged in extreme attention-seeking behaviors, and were able to calm down when they were upset and even talk about their feelings. I’ve seen it work with less intense cases, too, but those aren’t as fun to write about. PCIT works. 

PCIT can treat most concerns related to children’s behavior. This includes ADHD, anxiety disorder, autism spectrum disorder, oppositional defiant disorder (ODD), selective mutism, trauma-exposed children, and more.

So What Is PCIT?

Parent-Child Interaction Therapy is an evidence-based approach that has 50 years of research behind it. Research shows it keeps children out of therapy for up to seven years, when they hit adolescence and their brain begins to rewire. Lots of the skills you will learn in PCIT will always be relevant — many of them are as good with 6-year-old kids as they are with teens or even adults. PCIT is not a therapy where another adult takes your child and works with them for an hour before bringing them back to you, and you don’t know what they did in that hour. As a therapist, I love working with this age range because I know early intervention is key. (Also, angry 5-year-olds throwing chairs aren’t nearly as scary as angry 14- or 15-year-olds.)

How Does PCIT Work?

There are two phases to PCIT. The first phase is called Child-Directed Interaction, or CDI. I like to picture CDI as laying the stable foundation of a house. CDI teaches you the skills that play therapists use. It helps you begin to enjoy playing with your child again and learn how to manage their behavior with positive attention alone. In this first phase, you’ll already see a huge reduction in behavior issues due to the child receiving quality, purposeful time with the adult and the adult learning many new tactics to manage that child’s behavior without yelling or accidentally reinforcing the behavior. This is foundational work.

The second phase is called Parent-Directed Interaction, or PDI. PDI is where you get specific discipline skills to help you control your child’s behavior. Now that the relationship foundation is completely stable and your skills are memorized, we can move into learning how to consistently and effectively discipline your child.

Throughout PCIT, you’ll track the reduction in your child’s problematic behavior on a form called an Eyberg Child Behavior Inventory, or ECBI. As a parent, you get to rate your child’s behaviors and see how those behaviors change as treatment goes on.

Is PCIT Forever?

Great news! You will graduate from PCIT in as little as 3-6 months if you do the homework and work hard in sessions. PCIT is not a vague therapy where things end when it feels right; there are specific guidelines and instructions on how to graduate from therapy, all of which are parent-driven. 

How Does PCIT Compare to Other Therapies?

Ideally, because PCIT builds that strong foundation in the Child-Directed Interaction phase, it should be done before any other therapy, even before trauma therapy. Trauma therapy does include several PCIT elements; thus, it is done after PCIT. PCIT should especially be done before talk therapy, as PCIT has the research base behind it. Once kids feel safe and secure in their relationship with their parents, and once parents know how to consistently handle their child’s behaviors, then other therapies can be attempted. However, they usually are not needed at that point. 

Is PCIT Covered by Insurance?

Yes, as long as your insurance has mental health care coverage and your therapist accepts insurance or is able to be an out-of-network provider, PCIT should be covered.

 To learn more about PCIT, please visit this PCIT info page and PCIT International’s page for parents.

 If you live in Virginia and want to start online PCIT for your child, please visit check out Mary’s practice, Willow Tree Healing Center.  You can find more therapists who use PCIT by searching for therapists in your area and filtering your results by Type of Therapy > Parent-Child Interaction Therapy. 

Understanding Intergenerational Trauma: An Introduction for Clinicians

January 8, 2021 • By Dr. Fabiana Franco, PhD, DAAETS

by Dr. Fabiana Franco, PhD, DAEETS
Simple trauma describes a single, circumscribed traumatic event (such as an assault). Complex trauma occurs when a person experiences a series of repeated traumatic events or when new, unique traumatic incidents occur such as natural disasters. Complex trauma early in life can damage multiple aspects of the child’s development. Complex trauma may involve entire families in incidents of violence, addiction, or poverty. (1)

Historical Trauma

Historical trauma refers to traumatic experiences or events that are shared by a group of people within a society, or even by an entire community, ethnic, or national group. Historical trauma meets three criteria: widespread effects, collective suffering, and malicious intent (2). Historical Trauma Response (HTR) can manifest as substance abuse, suicidal thoughts, depression, anxiety, low self-esteem, anger, violence, and difficulty in emotional regulation (3)

Intergenerational Trauma

Intergenerational trauma (sometimes referred to as trans- or multigenerational trauma) is defined as trauma that gets passed down from those who directly experience an incident to subsequent generations. Intergenerational trauma may begin with a traumatic event affecting an individual, traumatic events affecting multiple family members, or collective trauma affecting larger community, cultural, racial, ethnic, or other groups/populations (historical trauma). Those affected by intergenerational trauma might experience symptoms similar to that of post-traumatic stress disorder (PTSD), including hypervigilance, anxiety, and mood dysregulation.

Intergenerational trauma was first identified among the children of Holocaust survivors (4), but recent research has identified intergenerational trauma among other groups such as indigenous populations in North America and Australia (3)(5). In 1988, one study showed that children of Holocaust survivors were overrepresented in psychiatric referrals by 300% (6). The subjects were selected based on having at least one parent or grandparent who was a survivor.

Parenting as an Explanation for the Phenomenon of Intergenerational Trauma

While the existence of intergenerational trauma is well documented in multiple studies across several cultures, the mechanisms of transmission of intergenerational trauma remain unclear.

Trauma’s Effects on Parents

Parents may transmit inborn genetic vulnerabilities triggered by their own traumatic experience or via parenting styles that have been impacted by their trauma (7). Trauma survivors face many challenges when they are parents, including difficulty bonding to and creating healthy emotional attachments with their children. Yael Danieli categorized four adaptation styles amongst the families of survivors: Numb, Victim, Fighters, and Those Who Made It. Survivors who become numb seek silence by self-isolating, have a very low tolerance for stimulation of any kind, and are minimally involved in raising their children. Victims fear and distrust the outside world, try to remain inconspicuous, and are frequently depressed and quarrelsome. Fighters focus on succeeding at all costs and retaining an armor of strength, making them intolerant of weakness or self-pity. Those Who Made It are characterized by their pursuit of socio-economic success but also by the ways in which they intentionally distance themselves both from their experience of trauma and from other survivors (8).

Effects on Children

Children experience and understand the world primarily through direct caregivers and are, therefore, profoundly affected by their parents’ modeling. Children both mimic their parents’ behaviors and learn to navigate future relationships based on how they learned to relate to their parents. Enduring coping mechanisms due to the effects of trauma may be forged out of efforts to avoid and/or “fix” a parent’s abusive behavior, anger, depression, neglect, or other problematic behaviors.

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The Great Famine in Ukraine of 1932-1933 and Intergenerational Trauma 

The Holodomor (derived from the Ukrainian “to kill by starvation”‘) is also known as the Famine-Genocide in Ukraine, the Terror-Famine, the Great Famine, or the Ukrainian Genocide of 1932–33. It resulted from deliberate actions on the part of the authorities in Soviet Ukraine who, under the direction of Joseph Stalin, sought to force collectivization on the ethnic Ukrainian peasant population. This resulted in the deaths of millions (11).

In 2010, Brent Bezo conducted a pilot study to understand the generational impact of the Holodomor. Bezo interviewed 45 people from three generations of 15 Ukrainian families. The first generation survived through the Holodomor: the second and third generations were their children and grandchildren.

The study revealed that the coping mechanisms that the direct survivors had developed during the genocide were retained in the family system and passed down to their children and grandchildren. They described living in “survival mode,” including difficulty trusting people, a food-scarcity mentality, low self-worth, hoarding, social hostility, and risky health behaviors (10).

Aboriginal Communities in Canada and Intergenerational Trauma 

Aboriginal communities in Canada suffered from sustained trauma. For generations, Canada tried to forcibly assimilate Aboriginal people by placing them in residential schools, removing children from their families, and generally attempting to eradicate their culture and traditions (5).

The effects of this prolonged trauma have impacted First Nations groups on individual and collective levels, including markedly high rates of depression and self-destructive behaviors compared to the non-Aboriginal population. One of the challenges for mental health professionals working with community members is to understand the effects of intergenerational trauma on their clients, including a well-earned mistrust in the ministries of outsiders.

When Trauma is not Acknowledged – Learning From the Armenian Genocide

Mental health professionals are often unfamiliar with the history of those they seek to treat. Unrecognized and, therefore, unacknowledged traumatic events, such as family trauma or childhood trauma will go on to pose unique challenges for both client and clinician.

Trauma Denied

The Armenian Genocide, during which the Ottoman Turkish Empire massacred 1.5 million Armenians in 1915, is an example of historical trauma that has often been either minimized or denied outright. In fact, the mass murder of Armenians, Assyrian, Greek, and other Christian and religious minority populations of the Ottoman Empire between 1914 and 1923 has yet to be acknowledged as a genocide by the Turkish government (11). It can be especially challenging to cope with an injury while you are still fighting for its acknowledgment a century after it was inflicted. Additionally, due to this lack of formal recognition, Armenian survivors find it difficult to trust non-Armenian mental health professionals with their history and pain (12).

Coping: Family Closeness

Dagirmanjian suggested narrative therapy as a treatment with Armenians (12). Narrative therapy allows survivors to embody and settle into their perception and view of themselves (11). Another important key to working with Armenians is understanding the way Armenians value family closeness. This trait has sometimes been misunderstood and even considered unhealthy by Western clinicians who have been trained to approach family therapy with the goal of promoting individuation (12). In general, it is crucial for the mental health professional to understand the cultural context of the person suffering from trauma, including intergenerational trauma, to provide the most effective and sensitive treatment.

When Trauma Attacks the Core of a Person’s Identity 

Systematic attacks on a person or group’s identity, such as the Holocaust or the Aboriginal experience, are particularly damaging because identity and tradition are essential to perceived meaning in life. Victor Frankl, in his book, Man’s Search for Meaning, describes the imperative for people to feel securely connected to meaning in their life: without specific meaning, it is literally impossible to live (13).

In approaching survivors of historical trauma in which the intent was not only to inflict pain or kill but to demean and, ultimately, erase the identity of an entire people, the therapist must be aware that recovery requires the restoration of morale, identity, and purpose.

Culturally-Mindful Interventions

In Canada’s Aboriginal communities, intergenerational trauma treatment is complicated due to high substance use (which is itself likely a sequela of historical trauma). A valuable 2015 study (14) demonstrated the importance of blending Aboriginal and Western healing methods to treat intergenerational trauma when it was associated with substance use disorder among Aboriginal people in Canada (14). A vital element in this approach is reclaiming and recovering Aboriginal identity, including traditions, philosophies, and practices, and adapting them to current circumstances and needs. Programs that enhanced identity through cultural affiliations, increased cultural awareness through healing circles and family involvement, and were strongly influenced by traditional Aboriginal spirituality contributed significantly to decreases in substance use, domestic violence (which are often associated with substance use), and an overall increase in individual and communal healing (14).

The Role of Epigenetics in Intergenerational Transmission of Trauma 

Maternal stress and trauma are associated with health consequences for both mother and child, including low birth weight, fetal growth, and preterm delivery (15). The effect of maternal stress and trauma translate into additional risks for the infant later in life, including hypertension, heart disease, Type II diabetes mellitus, and even cancer (16).

Epigenetics refers to the study of heritable changes in gene expression in response to behavioral and environmental factors that do not change the underlying DNA sequence. In other words, epigenetics is the study of inherited changes in phenotypical properties without a difference in the inherited genetic makeup. Recent studies demonstrate that traumatic events can induce genetic changes in the parents, which may then be transmitted to their children with adverse effects (17).

In 2005, a study conducted to better understand the relationship between the PTSD symptoms of women exposed to the World Trade Center collapse on September 11, 2001, and their infant children’s cortisol levels found lower cortisol levels both in the mothers and their babies (18). Cortisol is a hormone released through the adrenal gland which helps regulate stress response. These findings speak to the importance of factoring epigenetic effects into our evolving understanding of how posttraumatic effects may be transmitted across generations (18).

Take Away Lessons for Mental Health Professionals Treating Intergenerational Trauma 

Intergenerational trauma may be transmitted through parenting behaviors, changes in gene expression, and/or other pathways that we have yet to understand fully. These may be biological, social, psychological, and/or a mixture of all three. As we trace these modes of transmission, practitioners will be better able to match interventions to specific factors that either propagate traumatic effects across generations or mitigate against their transmission. Different sources of intergenerational trauma will likely require different approaches. Innovative treatments for multigenerational trauma that borrow from indigenous cultures, acknowledge historical trauma, connect to group identity, and support survivors in finding meaning and purpose in their experience and that of their family and people are already providing practical tools for practitioners and point the way towards future progress for future generations.

References

(1) Courtois, C. A. (2008). Complex trauma, complex reactions: Assessment and treatment. Psychological Trauma: Theory, Research, Practice, and Policy, S(1), 86-100. Accessed August 24, 2017.

(2) O’Neill L, Fraser T, Kitchenham A, McDonald V (June 2018). “Hidden Burdens: a Review of Intergenerational, Historical and Complex Trauma, Implications for Indigenous Families”. Journal of Child & Adolescent Trauma. 11 (2): 173–186.

(3) Maria Yellow Horse Brave Heart “The historical trauma response among natives and its relationship to substance abuse: A Lakota illustration.” Journal of Psychoactive Drugs 35(1).

(4) Fossion P, Rejas MC, Servais L, Pelc I, Hirsch S (2003). “Family approach with grandchildren of Holocaust survivors”. American Journal of Psychotherapy. 57 (4): 519–27.

(5) Aguiar, W. & Halseth, R. (2015). Aboriginal peoples and Historic Trauma: The processes of intergenerational transmission. Prince George, BC: National Collaborating Centre for Aboriginal Health.

(6) Sigal, J. J., Dinicola, V. F., & Buonvino, M. (1988). Grandchildren of Survivors: Can Negative Effects of Prolonged Exposure to Excessive Stress be Observed Two Generations Later? The Canadian Journal of Psychiatry, 33(3), 207–212.

(7) Bowers, M. E., & Yehuda, R. (2016). Intergenerational Transmission of Stress in Humans. Neuropsychopharmacology: official publication of the American College of Neuropsychopharmacology, 41(1), 232–244.

(8) Danieli, Y. (1981). Differing adaptational styles in families of survivors of the Nazi Holocaust: Some implications for treatment. Children Today, 10: 6-10.

(9) Werth, Nicolas. 2007. “La grande famine ukrainienne de 1932–1933.” In La terreur et le désarroi: Staline et son système, edited by N. Werth. Paris. ISBN 2-262-02462-6. p. 132.

(10) DeAngelis, T. (2019, February). The legacy of trauma. Monitor on Psychology, 50(2). http://www.apa.org/monitor/2019/02/legacy-trauma

(11) Mangassarian, Selina L. (2016). 100 Years of Trauma: the Armenian Genocide and Intergenerational Cultural Trauma, Journal of Aggression, Maltreatment & Trauma, 25:4, 371-381

(12) Dagirmanjian, S. (2005). Armenian families. In G. McGoldrick & N. Garcia-Preto (Eds.), Ethnicity and family therapy (pp. 437–450). New York, NY: Guilford.

(13) Frankl, V. E. (1984). Man’s search for meaning: An introduction to logotherapy. New York: Simon & Schuster.

(14) Marsh, T.N., Coholic, D., Cote-Meek, S. et al. Blending Aboriginal and Western healing methods to treat intergenerational trauma with substance use disorder in Aboriginal peoples who live in Northeastern Ontario, Canada. Harm Reduct J 12, 14 (2015).

(15) Dunkel-Schetter, C, Wadhwa, P, & Stanton, AL. (2000). Stress and reproduction: Introduction to the special section. Health Psychol; 19(6): 507-509.

(16) Barker, D. J. P. (1998). Mothers, babies and health in later life (2nd ed,). Edinburgh: Churchill Livingstone.

(17) Yehuda R, Bierer LM (2009). The relevance of epigenetics to PTSD: implications for the DSM-V. J Trauma Stress 22: 427–434.

(18) Yehuda, Rachel, Mulherin Engel, Stephanie, Brand, Sarah R., Seckl, Jonathan, Marcus, Sue M., Berkowitz, Gertrud S., Transgenerational Effects of Posttraumatic Stress Disorder in Babies of Mothers Exposed to the World Trade Center Attacks during Pregnancy, The Journal of Clinical Endocrinology & Metabolism, Volume 90, Issue 7, 1 July 2005, Pages 4115–4118.

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© Copyright 2021 GoodTherapy.org. All rights reserved. Permission to publish granted by Dr. Fabiana Franco, PhD, DAAETS