Alison M. Herum., MD

Intergenerational trauma often proves to be a prevailing feature of family systems.

The trauma of the Nazi concentration camps, for example, can be re-experienced in the lives of the children of camp survivors. Even the grandchildren of Holocaust survivors have been found to suffer from the effects of trauma. These effects manifest through characteristics such as increased suspiciousness of others, anger, and irritability in these individuals compared with controls (J. Relig. Health 2011;50:321-9).

Such intergenerational trauma has been found among urban American Indian and Alaska Native populations who have been involved in culturally specific sobriety maintenance programs (Am. Indian Alsk. Native Ment. Health Res. 2011;18:17-40). Likewise, a body of research supports the notion that untreated intergenerational trauma tied to generations of slavery in the United States continues to negatively affect many in the black community.

Other kinds of trauma can be passed down through the generations, as well. Take the trauma of a combat soldier; victim of or prisoner of war; survivor of a mass shooting or of child abuse; witness of genocide; or survivor of colonial suppression, slavery, or political totalitarianism. People who have experienced these traumas can pass down the consequences to subsequent generations.

We know that people who suffer trauma firsthand often develop posttraumatic stress disorder symptoms (PTSD) symptoms such as fearfulness, nightmares, flashbacks, sorrow, and difficulty with emotional closeness. However, it also is clear that compared with controls, the children of veterans with PTSD have shown an inability to experience appropriate emotional responses to situations and difficulty in solving problems effectively both within and outside the family unit (Aust. N.Z. J. Psychiatry 2001;35:345-51).

The trauma of childhood abuse also is transmitted down through the influences of the other members of the family, especially their children.

Another group known to suffer from the effects of intergenerational trauma is the children of alcoholics. This is a group that has demonstrated an increased need to care for others and keep secrets. They might use lying as a normal coping style and sometimes experience difficulty being children. Such behaviors are understood as a direct consequence of the experience of the family dysfunction. The question about trauma is: How do the symptoms of PTSD get "passed down" through the next generations, when the younger family members were not exposed to any trauma?

Various mechanisms have been considered, with individual psychological mechanisms and family dynamics being the most commonly cited mechanisms. Other factors have been suggested, such as the role of cultural and societal factors in the perpetuation of symptoms. Children and young adults might develop retaliatory fantasies "to right the wrongs done to their families." These types of beliefs and fantasies fuel many sectarian struggles around the world.

Individual psychological mechanisms commonly considered to be important are projection and identification. The parent with PTSD projects unwanted aspects of himself onto the child, who takes up the projection and identifies with it; this is called projective identification. Fear of the cold or the dark in the father then becomes the child’s fear instead. Children who are closest to the traumatized parent will be most affected.

Other postulated mechanisms focus on affect regulation. Parents who have difficulty with emotional regulation will have difficulty bonding appropriately with their child. On the other hand, emotional numbing might be present, which interferes with the development of a strong bond between parent and child.

One study of male Vietnam veterans found that "emotional numbing" and the quality of their relationship with their children remained significant even after investigators controlled for numerous factors, including the fathers’ family-of-origin stressors, combat exposure, depression, and substance abuse (J. Trauma Stress 2002;15:351-7). In other words, the children then suffer from secondary trauma.

Trauma-affected families also might have difficulty setting appropriate boundaries between parent and child so that the child becomes the caregiver of sorts and protector of the parent. The fears of the parent can become the fears of the child. It might be confusing for the child when a parent says: "Shh! Did you hear that noise," implying that "they" will get us, without really specifying the who and why, thus depriving the child of a rational explanation of his or her own experiences.

However, sometimes, trauma is not transmitted intergenerationally, a series of meta-analyses shows (Attach. Hum. Dev. 2008;10:105-21). Instead, these families are able to develop resilience and adapt well in the face of adversity – and achieve posttraumatic growth. How do we help the families with trauma become these resilient families?

Here is a list of nine points that can help guide the family psychiatrist:

1. The ability to regulate emotions, especially negative affect, is key to maintaining an understandable emotional climate for others in the family. Frequent unexplained emotional outbursts are difficult for other family members to understand. For children, it is especially important for them to understand that any emotional dysregulation is not caused by their behavior but by the parent’s experience of prior trauma.

2. The family should have an understanding of the meaning and cause of the traumatic events.

The traumatic events must be symbolized in a way that allows conversation and discussion about the past. The mention of wartime trauma can be phrased in a way that allows for the experience of pain, and then recovery, with hope and resilience as the message. A narrative story is important, with a good ending that the parent has survived, has overcome difficulties, and is here in the present with the child.

3. The parent must have "worked through" the trauma to the extent that he can internally symbolize his experiences enough to be able to talk about them and relay them to his

offspring in a coherent narrative with a positive message.

4. Open communication about the trauma prevents any unsymbolized, unspoken aspects of the trauma from being driven into unconsciousness, where they become dark fearful secrets that haunt the imagination and awaken the children, even as adults, at night.

5. Being able to access public accounts of the traumatic events is helpful to widen the family’s understanding of how others are affected, thus reducing the fearfulness of being alone with the trauma. Families should be encouraged to access these sources in order to understand the global aspects of trauma and the associated suffering and recovery.

6. For many families, having suffered trauma means that they must always be prepared for disaster. This, too, can be framed in a positive way, more like the scout motto of "be prepared," rather than the fearful posture of the survivalist.

7. A family fleeing from trauma might experience displacement through immigration and have no sense of home. This can be modulated by reestablishing and developing a new sense of community, and developing strong social and family rootedness. Sometimes, this involves a religious or spiritual group affiliation.

8. Family members who have suffered trauma often can identify skills that helped them survive. Hope, education, community, art – these values can be transmitted as the positive legacy of trauma. Helping families identify with positive resilient features of surviving trauma does not mean forgetting about the trauma but identifying the aspects that help the family go forward, enabling them to develop a narrative that allows recovery and growth.

9. If the child or other family members develop ongoing secondary PTSD or have enduring feelings of survivor guilt, persecution, and so on that are not resolved by family intervention, individual assessment might be needed.

In conclusion, despite the many illuminating case reports and anecdotes about the intergenerational transmission of trauma (for example, see J. Marital Fam. Ther. 2004;30:45-59), the message to families must be resilience focused. The question for these families becomes: "What did you do to manage the trauma and survive?"

Using a narrative framework, we can help these families identify the factors that can contribute to resilience, and build a future for the family that does not transmit traumatic symptoms but rather transmits the ability to move forward, despite traumatic symptoms.

 E-mail Dr. Heru at cpnews@elsevier.com.

Intergenerational trauma often proves to be a prevailing feature of family systems.

The trauma of the Nazi concentration camps, for example, can be re-experienced in the lives of the children of camp survivors. Even the grandchildren of Holocaust survivors have been found to suffer from the effects of trauma. These effects manifest through characteristics such as increased suspiciousness of others, anger, and irritability in these individuals compared with controls (J. Relig. Health 2011;50:321-9).

Such intergenerational trauma has been found among urban American Indian and Alaska Native populations who have been involved in culturally specific sobriety maintenance programs (Am. Indian Alsk. Native Ment. Health Res. 2011;18:17-40). Likewise, a body of research supports the notion that untreated intergenerational trauma tied to generations of slavery in the United States continues to negatively affect many in the black community.

Other kinds of trauma can be passed down through the generations, as well. Take the trauma of a combat soldier; victim of or prisoner of war; survivor of a mass shooting or of child abuse; witness of genocide; or survivor of colonial suppression, slavery, or political totalitarianism. People who have experienced these traumas can pass down the consequences to subsequent generations.

We know that people who suffer trauma firsthand often develop posttraumatic stress disorder symptoms (PTSD) symptoms such as fearfulness, nightmares, flashbacks, sorrow, and difficulty with emotional closeness. However, it also is clear that compared with controls, the children of veterans with PTSD have shown an inability to experience appropriate emotional responses to situations and difficulty in solving problems effectively both within and outside the family unit (Aust. N.Z. J. Psychiatry 2001;35:345-51).

The trauma of childhood abuse also is transmitted down through the influences of the other members of the family, especially their children.

Another group known to suffer from the effects of intergenerational trauma is the children of alcoholics. This is a group that has demonstrated an increased need to care for others and keep secrets. They might use lying as a normal coping style and sometimes experience difficulty being children. Such behaviors are understood as a direct consequence of the experience of the family dysfunction. The question about trauma is: How do the symptoms of PTSD get "passed down" through the next generations, when the younger family members were not exposed to any trauma?

Various mechanisms have been considered, with individual psychological mechanisms and family dynamics being the most commonly cited mechanisms. Other factors have been suggested, such as the role of cultural and societal factors in the perpetuation of symptoms. Children and young adults might develop retaliatory fantasies "to right the wrongs done to their families." These types of beliefs and fantasies fuel many sectarian struggles around the world.

Individual psychological mechanisms commonly considered to be important are projection and identification. The parent with PTSD projects unwanted aspects of himself onto the child, who takes up the projection and identifies with it; this is called projective identification. Fear of the cold or the dark in the father then becomes the child’s fear instead. Children who are closest to the traumatized parent will be most affected.

Other postulated mechanisms focus on affect regulation. Parents who have difficulty with emotional regulation will have difficulty bonding appropriately with their child. On the other hand, emotional numbing might be present, which interferes with the development of a strong bond between parent and child.

One study of male Vietnam veterans found that "emotional numbing" and the quality of their relationship with their children remained significant even after investigators controlled for numerous factors, including the fathers’ family-of-origin stressors, combat exposure, depression, and substance abuse (J. Trauma Stress 2002;15:351-7). In other words, the children then suffer from secondary trauma.

Trauma-affected families also might have difficulty setting appropriate boundaries between parent and child so that the child becomes the caregiver of sorts and protector of the parent. The fears of the parent can become the fears of the child. It might be confusing for the child when a parent says: "Shh! Did you hear that noise," implying that "they" will get us, without really specifying the who and why, thus depriving the child of a rational explanation of his or her own experiences.

However, sometimes, trauma is not transmitted intergenerationally, a series of meta-analyses shows (Attach. Hum. Dev. 2008;10:105-21). Instead, these families are able to develop resilience and adapt well in the face of adversity – and achieve posttraumatic growth. How do we help the families with trauma become these resilient families?

Here is a list of nine points that can help guide the family psychiatrist:

1. The ability to regulate emotions, especially negative affect, is key to maintaining an understandable emotional climate for others in the family. Frequent unexplained emotional outbursts are difficult for other family members to understand. For children, it is especially important for them to understand that any emotional dysregulation is not caused by their behavior but by the parent’s experience of prior trauma.

2. The family should have an understanding of the meaning and cause of the traumatic events.

The traumatic events must be symbolized in a way that allows conversation and discussion about the past. The mention of wartime trauma can be phrased in a way that allows for the experience of pain, and then recovery, with hope and resilience as the message. A narrative story is important, with a good ending that the parent has survived, has overcome difficulties, and is here in the present with the child.

3. The parent must have "worked through" the trauma to the extent that he can internally symbolize his experiences enough to be able to talk about them and relay them to his

offspring in a coherent narrative with a positive message.

4. Open communication about the trauma prevents any unsymbolized, unspoken aspects of the trauma from being driven into unconsciousness, where they become dark fearful secrets that haunt the imagination and awaken the children, even as adults, at night.

5. Being able to access public accounts of the traumatic events is helpful to widen the family’s understanding of how others are affected, thus reducing the fearfulness of being alone with the trauma. Families should be encouraged to access these sources in order to understand the global aspects of trauma and the associated suffering and recovery.

6. For many families, having suffered trauma means that they must always be prepared for disaster. This, too, can be framed in a positive way, more like the scout motto of "be prepared," rather than the fearful posture of the survivalist.

7. A family fleeing from trauma might experience displacement through immigration and have no sense of home. This can be modulated by reestablishing and developing a new sense of community, and developing strong social and family rootedness. Sometimes, this involves a religious or spiritual group affiliation.

8. Family members who have suffered trauma often can identify skills that helped them survive. Hope, education, community, art – these values can be transmitted as the positive legacy of trauma. Helping families identify with positive resilient features of surviving trauma does not mean forgetting about the trauma but identifying the aspects that help the family go forward, enabling them to develop a narrative that allows recovery and growth.

9. If the child or other family members develop ongoing secondary PTSD or have enduring feelings of survivor guilt, persecution, and so on that are not resolved by family intervention, individual assessment might be needed.

In conclusion, despite the many illuminating case reports and anecdotes about the intergenerational transmission of trauma (for example, see J. Marital Fam. Ther. 2004;30:45-59), the message to families must be resilience focused. The question for these families becomes: "What did you do to manage the trauma and survive?"

Using a narrative framework, we can help these families identify the factors that can contribute to resilience, and build a future for the family that does not transmit traumatic symptoms but rather transmits the ability to move forward, despite traumatic symptoms.

 E-mail Dr. Heru at cpnews@elsevier.com.

Intergenerational trauma often proves to be a prevailing feature of family systems.

The trauma of the Nazi concentration camps, for example, can be re-experienced in the lives of the children of camp survivors. Even the grandchildren of Holocaust survivors have been found to suffer from the effects of trauma. These effects manifest through characteristics such as increased suspiciousness of others, anger, and irritability in these individuals compared with controls (J. Relig. Health 2011;50:321-9).

Such intergenerational trauma has been found among urban American Indian and Alaska Native populations who have been involved in culturally specific sobriety maintenance programs (Am. Indian Alsk. Native Ment. Health Res. 2011;18:17-40). Likewise, a body of research supports the notion that untreated intergenerational trauma tied to generations of slavery in the United States continues to negatively affect many in the black community.

Other kinds of trauma can be passed down through the generations, as well. Take the trauma of a combat soldier; victim of or prisoner of war; survivor of a mass shooting or of child abuse; witness of genocide; or survivor of colonial suppression, slavery, or political totalitarianism. People who have experienced these traumas can pass down the consequences to subsequent generations.

We know that people who suffer trauma firsthand often develop posttraumatic stress disorder symptoms (PTSD) symptoms such as fearfulness, nightmares, flashbacks, sorrow, and difficulty with emotional closeness. However, it also is clear that compared with controls, the children of veterans with PTSD have shown an inability to experience appropriate emotional responses to situations and difficulty in solving problems effectively both within and outside the family unit (Aust. N.Z. J. Psychiatry 2001;35:345-51).

The trauma of childhood abuse also is transmitted down through the influences of the other members of the family, especially their children.

Another group known to suffer from the effects of intergenerational trauma is the children of alcoholics. This is a group that has demonstrated an increased need to care for others and keep secrets. They might use lying as a normal coping style and sometimes experience difficulty being children. Such behaviors are understood as a direct consequence of the experience of the family dysfunction. The question about trauma is: How do the symptoms of PTSD get "passed down" through the next generations, when the younger family members were not exposed to any trauma?

Various mechanisms have been considered, with individual psychological mechanisms and family dynamics being the most commonly cited mechanisms. Other factors have been suggested, such as the role of cultural and societal factors in the perpetuation of symptoms. Children and young adults might develop retaliatory fantasies "to right the wrongs done to their families." These types of beliefs and fantasies fuel many sectarian struggles around the world.

Individual psychological mechanisms commonly considered to be important are projection and identification. The parent with PTSD projects unwanted aspects of himself onto the child, who takes up the projection and identifies with it; this is called projective identification. Fear of the cold or the dark in the father then becomes the child’s fear instead. Children who are closest to the traumatized parent will be most affected.

Other postulated mechanisms focus on affect regulation. Parents who have difficulty with emotional regulation will have difficulty bonding appropriately with their child. On the other hand, emotional numbing might be present, which interferes with the development of a strong bond between parent and child.

One study of male Vietnam veterans found that "emotional numbing" and the quality of their relationship with their children remained significant even after investigators controlled for numerous factors, including the fathers’ family-of-origin stressors, combat exposure, depression, and substance abuse (J. Trauma Stress 2002;15:351-7). In other words, the children then suffer from secondary trauma.

Trauma-affected families also might have difficulty setting appropriate boundaries between parent and child so that the child becomes the caregiver of sorts and protector of the parent. The fears of the parent can become the fears of the child. It might be confusing for the child when a parent says: "Shh! Did you hear that noise," implying that "they" will get us, without really specifying the who and why, thus depriving the child of a rational explanation of his or her own experiences.

However, sometimes, trauma is not transmitted intergenerationally, a series of meta-analyses shows (Attach. Hum. Dev. 2008;10:105-21). Instead, these families are able to develop resilience and adapt well in the face of adversity – and achieve posttraumatic growth. How do we help the families with trauma become these resilient families?

Here is a list of nine points that can help guide the family psychiatrist:

1. The ability to regulate emotions, especially negative affect, is key to maintaining an understandable emotional climate for others in the family. Frequent unexplained emotional outbursts are difficult for other family members to understand. For children, it is especially important for them to understand that any emotional dysregulation is not caused by their behavior but by the parent’s experience of prior trauma.

2. The family should have an understanding of the meaning and cause of the traumatic events.

The traumatic events must be symbolized in a way that allows conversation and discussion about the past. The mention of wartime trauma can be phrased in a way that allows for the experience of pain, and then recovery, with hope and resilience as the message. A narrative story is important, with a good ending that the parent has survived, has overcome difficulties, and is here in the present with the child.

3. The parent must have "worked through" the trauma to the extent that he can internally symbolize his experiences enough to be able to talk about them and relay them to his

offspring in a coherent narrative with a positive message.

4. Open communication about the trauma prevents any unsymbolized, unspoken aspects of the trauma from being driven into unconsciousness, where they become dark fearful secrets that haunt the imagination and awaken the children, even as adults, at night.

5. Being able to access public accounts of the traumatic events is helpful to widen the family’s understanding of how others are affected, thus reducing the fearfulness of being alone with the trauma. Families should be encouraged to access these sources in order to understand the global aspects of trauma and the associated suffering and recovery.

6. For many families, having suffered trauma means that they must always be prepared for disaster. This, too, can be framed in a positive way, more like the scout motto of "be prepared," rather than the fearful posture of the survivalist.

7. A family fleeing from trauma might experience displacement through immigration and have no sense of home. This can be modulated by reestablishing and developing a new sense of community, and developing strong social and family rootedness. Sometimes, this involves a religious or spiritual group affiliation.

8. Family members who have suffered trauma often can identify skills that helped them survive. Hope, education, community, art – these values can be transmitted as the positive legacy of trauma. Helping families identify with positive resilient features of surviving trauma does not mean forgetting about the trauma but identifying the aspects that help the family go forward, enabling them to develop a narrative that allows recovery and growth.

9. If the child or other family members develop ongoing secondary PTSD or have enduring feelings of survivor guilt, persecution, and so on that are not resolved by family intervention, individual assessment might be needed.

In conclusion, despite the many illuminating case reports and anecdotes about the intergenerational transmission of trauma (for example, see J. Marital Fam. Ther. 2004;30:45-59), the message to families must be resilience focused. The question for these families becomes: "What did you do to manage the trauma and survive?"

Using a narrative framework, we can help these families identify the factors that can contribute to resilience, and build a future for the family that does not transmit traumatic symptoms but rather transmits the ability to move forward, despite traumatic symptoms.

 E-mail Dr. Heru at cpnews@elsevier.com.