Transcript emotional

How family members
express psychological
distress & resources in
war trauma?
Raija-Leena Punamäki, University of
Tampere, Finland
&
Samir Qouta & Eyad El Sarraj, Gaza
Community Mental Health Program, Gaza,
Palestine
© Raija-Leena Punamäki 2007
How family members
express psychological
distress & resources in
war trauma?
Raija-Leena Punamäki, University of
Tampere, Finland
&
Samir Qouta & Eyad El Sarraj, Gaza
Community Mental Health Program, Gaza,
Palestine
Study I
Impact on trauma on family
members’ psychological distress
& resources
© Raija-Leena Punamäki 2007
Family approach to war &
military violence



Family system provides the
parents & siblings distinct
roles & tasks
Emotional, cognitive &
behavioral ‘share of work’
Serves family’s survival,
adaptation & balance
© Raija-Leena Punamäki 2007
Impact of trauma on families



Family roles crystallize in the
face of threat, danger & trauma
If flexible & short-living, strict
roles enhance effective coping &
learning
If ‘cemented’ & permanent, they
prevent child development & can
form risks for mental health
problems
© Raija-Leena Punamäki 2007
Research hypotheses


Exposure to military trauma
differently impacts family
members’ mental health and
resiliency responses
Siblings & parents may show
compensatory and/or
symmetric vulnerability &
resiliency
© Raija-Leena Punamäki 2007
Participants: Palestinian
families in Gaza





65 quintets of three siblings,
mother & father
Siblings 13-, 15- & 18-year-olds
Follow-up sample from the
Intifada I: 108 target children,
then 8-year-olds
Boys 48%, girls 52%
70% from refugee camps, 20%
town, and 10% resettled areas
© Raija-Leena Punamäki 2007
© Raija-Leena Punamäki 2007
Measures



Traumatic events: (a) Military-related
10 items, e.g. loss of family members
as dead & detained, being wounded &
destruction & violence (b)Familyrelated: report of personal trauma:
illness, human conflicts
Mental health problems: PTSD,
depression & neuroticism
Resiliency responses: Quality of life
(satisfaction, vitality, fulfillment),
resiliency (creativity, persistency,
relationships) & self-esteem
© Raija-Leena Punamäki 2007
Result 1:
Trauma-related differences between family
members found in PTSD
PTSD among Family Members
according to Trauma
34
32
30
28
26
Level of trauma
F
th
r
e
r
8
1
3
1
5
1
e
th
a
d
il
d
il
d
il
o
M
High
h
C
22
h
C
Low
h
C
24
Family Members
© Raija-Leena Punamäki 2007
Total Scores
Result 2.
Trauma increases depressive symptoms in
all, no family-member differences
Depression among Family Members
according to Trauma
7
6
5
4
Level of Trauma
Low
3
h
C
h
C
h
C
High
3
1
5
1
y
y
r
e
th
o
rs
M
a
e
yer
t8h s
a1
r
a
d
il F
d
il
d
il
2
e
e
a
rs
Family Members
© Raija-Leena Punamäki 2007
Result 4:
High trauma associates with low quality of
life only among fathers
Quality of Life among Family
Members according to Trauma
Total Score
120
110
Level of Trauma
100
Low
C
C
C
h
h
h
d
d
High
1
1
3
5
r
e
th
o
rs
M
a
e
yr
8e
1th s
r
da
il F ea
y
il
il
90
y
e
a
rs
Family Members
© Raija-Leena Punamäki 2007
Result 5:
Only family membership, not trauma,
determines the level of resiliency
Resiliency among Family Members
according to the Level of Trauma
3,8
Means
3,7
3,6
3,5
Level of Trauma
3,4
Low
3,3
h
C
h
C
h
C
3
1
5
1
High
y
y
r
e
th
o
rs
M
a
e
yer
t8h s
a1
r
a
d
il F
d
il
d
il
3,2
e
e
a
rs
Family Members
© Raija-Leena Punamäki 2007
Result 6:
High trauma associates with low selfesteem among all siblings
Self-esteem among Siblings
according to Trauma
67
Total score
66
65
64
63
Level of Trauma
62
Low
h
C
h
C
h
C
High
d
il
d
il
d
il
61
60
8
1
3
1
5
1
y
y
y
rs
a
e
rs
a
e
rs
a
e
Siblings
© Raija-Leena Punamäki 2007
Figure 6.
Family Type and Traumatic Events
5
4,5
4
3,5
Military Trauma
3
2,5
Personal Trauma
O
rd
ea
l
Pa
Re
Ch
re
ild
si
lie
nt
re
al
nt
n'
Fa
S
s
F
m
tr
am
st
ily
en
re
ily
gh
ng
t
ht
© Raija-Leena Punamäki 2007
Conclusions

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Compensatory dynamics: Parents: fathers
resist PTSD, but vulnerable in quality of
life; mothers resilient if husband
vulnerable
Younger children ‘carry’ PTSD (intrusion,
avoidance & hyper arousal)
Typology showed clear generational
boundaries: resiliency (e.g. persistency &
support) in either parents or siblings:
Tailored interventions for families &
members
© Raija-Leena Punamäki 2007
Study II
Mother-child distress in extreme
trauma: destruction of home
© Raija-Leena Punamäki 2007
Research task:
Two alternatives how exposure to trauma
impacts mothers and their children’s
distress
 Accumulation and dose-effect: both suffer
when trauma severity increases
 Family systems approach: (a) ’share of
work’ in distress expression (b)
reciprocical worry (c) contamination &
specifity of symptom expression
© Raija-Leena Punamäki 2007
Participants: Mothers & their 6-16year-old children in Gaza

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121 families in destroyed areas
during the Al Aqsa Intifada
Part of an intervention study
Mothers & their 6-16-year-old
children
Boys 54.6%, girls 45.4%
© Raija-Leena Punamäki 2007
© Raija-Leena Punamäki 2007
Measures
Trauma exposure
 12 events including witnessing &
being the target (e.g. saw family
member killed, shelling of home,
being shot at)
 Mothers and children separately
reported
Mental health
 PTSD (Mothers: Allodi DSM ;
Children: Pynoos CPTS-Ri)
 Psychological distress (Mothers:
SCL_90,
Children: Rutter: RA2)
© Raija-Leena Punamäki 2007
Results
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Family systems model was
substantiated in girls
Accumulation model was
substantiated
in boys
Dyadic symptom expression
specificity:
Mother hostile – child externalizing
symptoms
© Raija-Leena Punamäki 2007
Family War Trauma and Children’s PTSD-symptoms
PTSD
among Boys and Girls
50
48
46
44
42
40
38
36
34
32
30
Boy
Girl
h
t
Bo
ild
Ch
h
ig
H
h
ig
h
ig
H
H
w
Lo
r
he
ot
M
h
t
Bo
Family War Trauma
© Raija-Leena Punamäki 2007
Symptoms
Maternal Depressive & Anxiety Symptoms according to
Family War Trauma
29
27
25
23
21
19
17
15
13
Depressive
Anxiety
w
Lo
h
ig
H
th
Bo
h
ig
H
ild
h
Ch
ig
rH
he
ot
M
h
t
Bo
Family War Trauma
© Raija-Leena Punamäki 2007
Importance of Attachment
(J. Bowlby, M. Ainsworth, M. Main, P. Crittenden)

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Child attachment behavior is
precondition for survival
Early working models of thrust, own
worth, safety & benevolence of the
world and others
In adulthood danger and trauma
activate attachment/working models
Crystallize responses typical to each
attachment style
© Raija-Leena Punamäki 2007
Study III
Adult Attachment & CognitiveEmotional Processing of trauma
© Raija-Leena Punamäki 2007
” Fatherhood of a national hero”
Oslo agreement (Israel & PLO, 1993):
8 000 political prisoners released
Motivation for seeking psychological
help:
* anger & intrusive memories harm
intimate
relationship
* feeling failure in being a father:
outsider
* numbing of feelings
(not so much for PTSD)
The ’big question’ how to process
trauma-related emotions
© Raija-Leena Punamäki 2007
Adult Attachment & emotions
Secure-balanced


Access to both negative & positive
feelings
Access to both emotions & cognition
Insecure-dismissing


Distrust emotions; minimizes feelings
Emphasis on analytic & cognitive
mode
Insecure-preoccupied

Distrust cognitions, ignores
information
© Raija-Leena Punamäki 2007
Multilevel Model of Emotions
(N.Fridja)
a) Domains of emotions
 Behavioral: action readiness
 Cognitive: appraisal & metacognitions
 Affective: feelings, mood
 Physiological level: arousal
b) Intensity and valence of emotions
c) Content & autobiographical meaning
© Raija-Leena Punamäki 2007
Study Hypotheses:
Emotional processing of trauma is
biased among insecurely
attached individuals:
 Dismissing use predominantly
cognitive modes
 Preoccupied use predominantly
emotional feeling states
© Raija-Leena Punamäki 2007


Secure individuals use
balanced emotional-cognitive
processing
Exposure to trauma activates
the attachment-specific
emotional processing
© Raija-Leena Punamäki 2007
Participants


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
153
Palestinian
men, Gaza
Political
prisoners
Released
accord. Oslo
agreement
19-50 yearolds
(29.4+5.7)
Education:
33%
university
© Raija-Leena Punamäki 2007
© Raija-Leena Punamäki 2007
© Raija-Leena Punamäki 2007
The Association between Trauma Exposure &
Posttraumatic Growth according
to Attachment Security
3.8
3.6
Low Secure
High Secure
3.4
3.2
Low Trauma
High Trauma
© Raija-Leena Punamäki 2007
The Association between Trauma &
Negative. Emotions according
to Avoidant Attachment
1.8
1.4
1
Low Avoidance
High Avoidance
0.6
0.2
Low Trauma
High Trauma
© Raija-Leena Punamäki 2007
Implications for trauma reseach
Multilevel analysis: Individual underlying
mechanisms: cognitive, emotional,
psychophysiological and hormonal
Family: Parental, sibling and transgenerational
subsystems, shared-nonshared environments
Culture: which processes are universal vs.
culture-related vs. both: cognitive, emotional,
social, biological
Reconsideration of Poortinga
model
 Developmental approach: infant psychology; new
understanding of adolescence; new look at
’critical periods’; brain development and
modulation
Family systems theory & Evolution psychology:
 Integration of attachment and trauma theory:

© Raija-Leena Punamäki 2007
Reseach Setting and Procedure
Before therapy
PERSONALITY
During therapy
After therapy
Adult attachment
Defence styles
THERAPY PROCESS
Alliance
Significant events
Feeling states
EMOTIONALCOGNITIVE
Self- and object
representations
Self- and object
representations
Self- and object
representations
Emotional
responses
Dreaming
Emotional
responses
PTSD
PTSD
PTSD
Somatic
symptoms
Somatic
symptoms
Somatic
symptoms
Personal growth
Personal growth
Personal growth
PROCESSING
MENTAL HEALTH
© Raija-Leena Punamäki 2007
Working with
traumatized families:
attachment theory
approach
Raija-Leena Punamäki, University of
Tampere
”War and attrocities destroy
homes”:



Concrete: e.g. 17 600 persons’
homes destroyed in Gaza 20012004
Many pregnant women & mothers
with infants live in tents & houses
of relatives
Symbolic: The question of security
& safety
© Raija-Leena Punamäki 2007
Importance of early motherhood



Mother anxiety in pregnancy >
more attention deficit, reading
difficulties
Mother depression in post-partum
>
aggressive & depressive
symptoms in preschool
Epidemiology: mothers pregnant in
war (Israel 1967) > more
© Raija-Leena Punamäki 2007
aggressive & depressive symptoms
© Raija-Leena Punamäki 2007
Importance of the first year
The first relationship with mother
creates inner models of:
 Whether safe place is available
 How to avoid rejection
 Whether to trust others and self
 How to express distress
 Whether to dare explore
© Raija-Leena Punamäki 2007
Importance of Attachment


The attachment a condition to survival
Attachment behavior activates when
experience of danger and threat:
Infancy:stranger & separation
Preschool: symbolic & real fears
Middle childhood: rejection &
incompetence
Adolescence: intimate relationships &
future
Adulthood: transition periods & stress &
© Raija-Leena Punamäki 2007
change
Attachment styles
in childhood
Attachment Safeseeking
style
Secure
Insecureavoidant
Insecureambivalent
Disorganised
Exploratio Emotional
n
responses
Active &
Seeks
curious
consoling
Adequate
distress, but
calming
down
Not
Active &
No distress
seeking
self& selfreliant
sufficient
Strong
Clinging
Not dare
expre.
&
to explore Not calming
obsessed
down
Not clear attachme Distress &
© Raija-Leena Punamäki 2007
Secure attachment style &
emotional development

Strenghts
• Inner model about the availability of care
• Experience of a mother’s sensitivity to
interpret her/his feelings in right way
• Feels secure enough to express strong,
real and also negative feelings
• A rich variety (repertoire) of feelings
• Knowledge that bad feelings can be
calmed down
• Internalized picture about how emotions
can be expressed and controlled

Vulnerabilities
© Raija-Leena Punamäki 2007
Avoidant attachment &
emotional development

Vulnerabilities
•
•
•
•
•
•

Experiences of rejection & disappointment
Difficultiy to recognize own emotions
Over control of emotions, ’too polite’
Falsified positive feelings
Narrow repertoire of feelings
Conflicts between physiological (arousal) &
subjective emotional expression
Strenghts
• Thrust in own coping & management
• High cognitive competence
© Raija-Leena Punamäki 2007
Ambivalent & emotional
development

Vulnerabilities
• Inner model of the parent as unpredictable,
absent, indifferent or even dangerous
• Difficult to control emotios; undercontrol
• Emotions ’flow over’, ’all the time on’
• Difficult to be consoled & calm down
• Strong emphasis on emotions, and possible
neglect of cognitive development (thinking,
reasoning, framing)

Strengths
• Repertoire and intensity of emotional
expression
© Raija-Leena Punamäki 2007
Trauma in early age
Event
Horror, Threat, Danger
•
•
Psychological
mechanisms
Arousal
Sensitivity
to danger
•
Sensomotor memory
• No episodes
•
•
Expressed
symptoms
•Nightmares
•Excessive fears
•Intrusions
•Arousal
Narroved
perceptions
Biased
interpretatios
No integration of
feeling & knowing
© Raija-Leena Punamäki 2007
Interaction between mother and
infant

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
Also the child has influence on the
interaction >> reciprocal relations
(Infant research)
The fit between the mother’s and
baby’s temperemant >> genetics
provide possibility (goodness-of-fit)
Interactional experiences accumulate
>> positive or negative
developmental paths start early
© Raija-Leena Punamäki 2007
Traumatic experiences



People have inner reflective
response models to threatening
situations
procedural (body) and episodic
(emotional) memory systems
develope early (associative brain;
limbic systems)
no direct link to the semantic
(intellectual) memory (cortex
developes slowly)
© Raija-Leena Punamäki 2007
Fear reactions in infants
generalize


Reaction sensitivity (cryig, distress):
easyly cries->protesting>defending->aggression
Dissosiation process:
when crying does not bring
consoling: avoiding crying -->
compulsive obediency (freezing) ->
dissosiation (non connecting
feelings and behavior)
© Raija-Leena Punamäki 2007
Mother-child at Risk: Intervention
effectiveness
- Content: psychoeducational at home
- Infant-led,
- Promoting parent-child
communication
- Focusing on the infant
idiosyncronatic cues;
- Feedback; maternal self-confidence;
- Comprehensive (all levels of infant
development)
- Long period
- Taylored specially to particular
© Raija-Leena Punamäki 2007
riskis!!
Mother-child at Risk: Intervention
effectiveness
• Similar results as usually preventive
interventions (mean effect size 0.34)
• More succesful with the first time mothers
(es 0.87)
(Review: Fonagy, 2000)
© Raija-Leena Punamäki 2007
Interventios: What can be
changed? How? When? By
whom?
Physiological
•reflects
•growing
Experiences
Psycho-motor
•coordination
•attention
•consistency
Cognitive
•speaking
•memory:
Maturation
procedural &
verbal
Emotional
•attachment
•emotional
expression
•recognition of
emotions
Social
•empathy
•friendship
© Raija-Leena Punamäki 2007
”Torture interferes fatherhood”
Oslo agreement (Israel & PLO, 1993):
8 000 political prisoners free
Torture systematic in Israeli prisonons
(Landau: slight psychological pressure)
Motivation for seeking psychological
help:
* anger & intrusive memories harm
intimate
relationship
* feeling failure in being a father:
© Raija-Leena Punamäki 2007
outsider
Trauma in adulthood
Traumatic
experience
Working
models

oneself

other people

world
Mental Health
Depression
PTSD
Somatization
?
Therapy
© Raija-Leena Punamäki 2007
Attachment theory: Adults
(J. Bowlby, M. Ainsworth, M. Main, P. Crittenden)



Understand the role of early
relations in shaping current
functioning
Inner working models
(representations) of oneself,
trusting others & safety
Cumulative development:
Attachment style organizes
behaviour, emotions, cognitions &
relationships
© Raija-Leena Punamäki 2007
Memory types (Tulving)




Sensory memory: visual (icon),
auditory (echo), smell, taste
Semantic memory: ”Copenhagen is in
DK”, ”People are basicly good”
Episodic & narrative memory: events,
stories, jokes
Prosedural memory: kinesthetic,
emotional states, ”body remembers”
© Raija-Leena Punamäki 2007
Adult Attachment:
Vulnerability & Resources
Secure-balanced
Innocent expectations of the world,
naivity
Lack of ’training’ with hardships

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
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Integrated & coherent memories
Both episodic & semantic memory
Access to unconscious processes
Realistic perceptions of events
© Raija-Leena Punamäki 2007
Reliance on others for help
Adult Attachment:
Vulnerability & Resources
Insecure-dismissing




Semantic memory predominates
Procedural memory of trauma & lack
of childhood memories
Distrust of others & social withdrawal
Minimize emotions, deny pain
Thrust in oneself
Interest in intellectual tasks
© Raija-Leena Punamäki 2007
Adult Attachment:
Vulnerability & Resources
Insecure-preoccupied





Emotional & narrative memories,
incoherent
Semantic memory, narrow
Past dominates & recurring feeling
states
Dependency & disappointment of
others
Ambivalent & conflicting relations
Intensive expression of emotions
© Raija-Leena Punamäki 2007
Arguments



Attachment is about protection from
danger
Danger and trauma activate and
crystallize responses typical to each
attachment style
Therapy with trauma victims should be
tailored either to match or to
compensate the unique vulnerabilities
and strengths
© Raija-Leena Punamäki 2007
Participants of the study




153
Palestinia
n men,
Gaza
Political
prisoners
Intifada I
19871993
Local
© Raija-Leena Punamäki 2007
Study I
Attachment & Trauma-related
Emotions
© Raija-Leena Punamäki 2007
Adult Attachment & emotions
Secure-balanced


Access to both negative & positive
Access to both emotions & cognition
Insecure-dismissing


Distrust emotions; minimizes
feelings
Emphasis on analytic & cognitive
mode
Insecure-preoccupied

Distrust cognitions, ignores
information
© Raija-Leena Punamäki 2007
Multilevel Model of Emotions
(N.Fridja)
Domains of emotions
 Behavioural: action readiness
 Cognitive: appraisal & metacognitions
 Affective: feelings, mood
 Physiological level: arousal
Intensity and valence of emotions
 Negative and positive
Content & autobiographical meaning
© Raija-Leena Punamäki 2007
Study Hypotheses:
Emotional processing of trauma is distorted
among insecurely attached individuals:


Dismissing use predominantly cognitive
modes
Preoccupied use predominantly emotional
feeling states
© Raija-Leena Punamäki 2007


Secure individuals use balanced
emotional-cognitive processing
Exposure to trauma activates the
attachment-specific emotional
processing
© Raija-Leena Punamäki 2007
© Raija-Leena Punamäki 2007
© Raija-Leena Punamäki 2007
Conclusions


Secure, Dismissing & Preoccupied
persons have unique resources and
vulnerabilities
Integrating traumatic experiences as
a part of personal history
The aim of therapy is to balance
between cognitive and emotional
processing

© Raija-Leena Punamäki 2007
Conclusions
Insecure attachment is not an inherent
risk for psychopathology
Secure attachment is not a general
’protective factor’
The nature of trauma is decisive:
”degree of intimacy”
Activation of danger-related working
models is informative
© Raija-Leena Punamäki 2007
Therapy & Interventions should
be tailored accordingly



Dismissing clients ”feel home” with
semantic-causal mode;
important to learn to recognize,
express and value feelings
Preoccupied clients escalate emotional
responses and ignore cognitive cues;
therapy should integrate
both modalities
Secure clients often satisfy with
psychoeducational approach
© Raija-Leena Punamäki 2007
Study II
Attachment & Working alliance



Working alliance = bonding & goal
setting in the therapy
Good alliance predicts successful
therapy outcomes
Changes in alliance predicts good
outcomes
© Raija-Leena Punamäki 2007
Reseach Setting and Procedure
Before therapy
PERSONALITY
During therapy
After therapy
Adult attachment
Defence styles
THERAPY PROCESS
Alliance
Significant events
Feeling states
EMOTIONALCOGNITIVE
Self- and object
representations
Self- and object
representations
Self- and object
representations
Emotional responses
Dreaming
Emotional responses
PTSD
PTSD
PTSD
Somatic symptoms
Somatic symptoms
Somatic symptoms
Personal growth
Personal growth
Personal growth
PROCESSING
MENTAL HEALTH
© Raija-Leena Punamäki 2007
Research setting
at the
after 5
beginnin
months
g
Individual
therapy
Group
therapy
No therapy
after 10
months
27
17
15
25
25
25
100
70
70
© Raija-Leena Punamäki 2007
Development of
Working Alliance
according to Attachment
© Raija-Leena Punamäki 2007
Results on Working Alliance
 PTSD symptoms decrease in intensive,
focused, individual treatment only
Attachment style is important in forming
working alliance


Dismissing clients dislike disclosure &

Preoccupied clients ’attach’ quickly,
sharing emotions -> poor alliance at the end
of therapy.
Feels home in cognitive domains -> good
alliance
at the middle of therapy
disappoint quickly -> diminishing alliance
-> very good alliance at the end © Raija-Leena Punamäki 2007
Therapy & Interventions should
be tailored accordingly


Dismissing clients ”feel home”
with semantic-causal mode;
important to learn to recognize,
express and value feelings
Preoccupied clients escalate
emotional responses and
ignore cognitive cues;
therapy should integrate
both modalities
© Raija-Leena Punamäki 2007
Measurements:
Attachment variables I
Paper-and-pencil measure, based on the
AAI
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Descriptions of childhood relationship
with mother and father
Descriptions of events of being ill,
upset & rejected as a child
Descriptions of memories of distress
& separation
© Raija-Leena Punamäki 2007
Measurements:
Attachment variables II
Cluster analysis of attachment patterns
What is remembered?
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Childhood memories of love,
rejection, neglect, over-involvement,
pressure to achieve
Dealing with distress: denial,
withdrawal, aggression, self-reliance,
seeking attention, consoling &
support
© Raija-Leena Punamäki 2007
Measurements:
Attachment variables III
How the experiences are remembered?
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Coherence of the answers: succinctly,
truthfully, clearly & logically
described
General incoherence
Current anger, idealization &
derogation
Memory modalities: semantic,
© Raija-Leena Punamäki 2007
Measurements:
Outcome variables

Harvard Trauma Questionnaire (HTQ)
(Mollica &Caspi-Yavin, 1991)
Intrusion; Avoidance, Hyperarousal

Somatic symptoms
(Allodi, 1985)
psychosomatic, aches, cardiological
problems

Positive growth (Callhoun, 1992)
personal strength, relating to others,
spirituality
© Raija-Leena Punamäki 2007
Experiences of Torture &
ill-treatment
Physical
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Beating hands and
legs
Jumping on the body
Torture by
application of
electricity
Burning with
cigarettes
Breaking bones
‘Crucification’
(hanging from
hands)
Psychological
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Personal humiliation
Threats towards family
members
Threats to cause
infertility
Confronted by false
accusations
Sham execution
Forced confession or
‘singing’
Forced to witness
torture of others
© Raija-Leena Punamäki 2007
Experiences of torture &
ill-treatment
Sexual
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Sexual
harassment
Beating on the
sexual organs
Attempted rape
Threats to rape
wife or sister
Sensory violation
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Hooding
Exposure to strong
light
Isolation and
solitary confinement
Food/water
deprivation
© Raija-Leena Punamäki 2007
Argument: war makes children
aggressive
© Raija-Leena Punamäki 2007
Development of aggression I
When are we the most aggressive?
 Peak of physical aggression 3.4 years
 Boys: physical aggression & verbal
aggression girls 12-14 years, the
decrease
 Adolescence aggression >>> depression
in adulthood
 Pre-school aggression >>> antisocial,
pathology, criminal
© Raija-Leena Punamäki 2007
Development of aggression I
Kinder-garten age:
 Physical aggression dominant
(biting, hitting, fights about toys)
 Changes to verbal aggression –
direct to undirect
Middle childhood
 Girls: verbal and indirect aggression
 Boys: physical aggression
Adolescents: Decreases
© Raija-Leena Punamäki 2007
Explanation models for
aggressive behavior
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Fear –modell:
* need for great stimulus & excitement
* punishment is effective
Empathy deficient:
* difficulty to recognize other people’s
feelings
* Interprets sadness & fear as hate
Regulation
* Escalaton & lack of control of anger
© Raija-Leena Punamäki 2007
Individual & social
aggression
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Children are differently ’vulnerable
No good or bad children
Parent-child relationship: punishment
or discussion, model or order
Risk for aggression:
* what we see & how we see
* interpretation & explanation
Aggressive behavior is revarded
© Raija-Leena Punamäki 2007
Interventions with
aggression
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Intervention & prevention aggression
is based on ’mediation from
vitnessing violence to becoming
violent
1) recognition & interpretation
2) regulation 1,2,3
3) alternative behavior
4) understanding causes
5) Humor & stories & narratives
© Raija-Leena Punamäki 2007
Prevention of aggression
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Individual & group: Recognition &
discrimination of emotions: sad, fear,
surprise
Training of causes & consequences
Relations: parents, peers, siblings
Community: No tolerance for violence
Clear rules for behavior
Alternatives exist
Political level: no victims, no
humiliation, no acceptance of revence
© Raija-Leena Punamäki 2007
Breaking the violent circle
Before intervention
 Not recognize own
excitement
 Interpret others as
threatening
 Emotions run
quickly
 Impossible to
control
 Does not remember
own aggression
 Behaves without
thinking
After Intervention
 Learn how stages of
’excitement’
develope
 Feelings base on
’reality’
 Feelings slow
tempo
 Conscious control
 Memory of
alternative behavior
 Behavior, feeling,
thinking ”bird level”
© Raija-Leena Punamäki 2007
Need for Intervention Targeting
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Intervention studies with communitysample method: More pronounced
intervention effects e.g. most benefits
for at-risk families (Olds 2002; Lee 2003)
Call for more targeted intervention
programs fore such families
Authors of at-risk intervention
programmes still call after more
research of targeting e.g. underlying
mechanisms and timing influences
(Seitz et al. 1985, Booth et al. 1992, Black et al.
1994, Dybdahl 2001, Kok et al. 2004).
© Raija-Leena Punamäki 2007
Need for Intervention Targeting



Intervention studies with communitysample method: More pronounced
intervention effects e.g. most benefits
for at-risk families (Olds 2002; Lee 2003)
Call for more targeted intervention
programs fore such families
Authors of at-risk intervention
programmes still call after more
research of targeting e.g. underlying
mechanisms and timing influences
(Seitz et al. 1985, Booth et al. 1992, Black et al.
1994, Dybdahl 2001, Kok et al. 2004).
© Raija-Leena Punamäki 2007
Methodological consideration of
community vs. at-risk samples
Community
based/
Selected
Primary/
risk-group
Universal
cases
Interventions
Risk-group/
Focused/
Secondary
interventions
In a
phase of
dataanalyzing
© Raija-Leena Punamäki 2007
The confusion of what has been done
(inside the intervention)
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”Much remains to be determined about
targeting, timing and spesific procedures
that are effective” (Seitz et al. 1985)
”How the intervention worked, however is
unknown, and more research is needed to
investigate the working factors in this
approach” (Dybdahl 2001)
” Addtional information is necessary to
identify how environmental factors facilitate
and maintain positive change” (Black et al.
1994)
© Raija-Leena Punamäki 2007
The confusion of critical variables
(between the interventions) Fonagy
1998
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The center of the intervention: child or
parent
Starting point of the intervention: during
pregnancy or at birth or during childhood,
Administration of intervention: nurses or
psychologists or other professionals or
volunteers,
Orientation of intervention: focused or
broad-based/ educational or behavioral or
relationship or psychodynamical
© Raija-Leena Punamäki 2007
What should be done?

” Vast resources are spent on aid programs. For
ethical as well as economical reasons it is important
to know what works best when and for whom.
Therefore, in spite of the obstacles, well-designed
and lareger scale evaluation studies are needed”
(Dybdahl 2001)


“The growing literature on prevention makes it
necessary to evaluate the impact of different
programs and determine which factors promote
better outcomes. “ (Durlak & Wells 1998)
We are still on the way of developing the full
potential of prevention (Olds, 2002), and on this road
we will need a guidance of scientific framework.
© Raija-Leena Punamäki 2007
Classifications of preventions
(physical illness)
Primary
decreasing the number of
new cases of a disorder
Universal
general public and for all
members of specific eligible
groups, such as pregnant
women
1957 Comission of
Chronic Illness
Secondary
lowering the rate of
established cases of the
disorder in the population
1983 Gordon (population
groups to whom
interventions are
directed)
Selective
subgroup of the population
whose risk of becoming ill is
above average
Tertiary
decreasing the amount of
disability associated with an
existing disorder .
Indicated
persons who are found to
manifest a risk factor that
identifies them as being at
high risk for the future
developmen
of a disease.
© Raija-Leena Punamäki 2007
Classifications of preventions
(mental illness)
Universal
general public or a whole population
group that has not been identified on the
basis of individual risk
IOM 1994
Selective
individuals or a subgroup of the
population whose risk of developing
mental disorders is significantly higher
than average
NIMH Workgroup of Mental Disorders
Prevention Research 1998
1.
participants who have no current
symptoms of mental disorder and were never
symptomatic
participants who have current sub-clinical
symptoms
Primary / Universal
improving child development, parenting
knowledge and behaviour, and infant
mental health for all families within their
service range
Zeanah et al. 2005
Focused / Targeted
specifically identified groups considered
at risk for developing potentially serious
social or emotional problems
2.
Indicated
high-risk individuals who are identified
as having minimal but detectable signs or
symptoms foreshadowing mental
disorders
3.
participants who
have currently
diagnosed disorder
and/or were
previously
symptomatic >the
emphasis is on
prevention
of relapse or
recurrence
4.
participants who
have a currently
diagnosed disorder,
with the
emphasis on
prevention of
comorbidity or
disability
Intensive / Tertiary
infants and caregivers experiencing
current difficulties, and also attempt to
prevent or lessen future problems
© Raija-Leena Punamäki 2007
The mental health intervention
spectrum for mental disorders.
(IOM 1994)
© Raija-Leena Punamäki 2007
...Classifications of preventions (mental illness)
Durlak & Wells 1997
Intervention
Population
Person
Environment
directly to the
target population
attemp to change
individuals
indirectly by
modifying the
environment
Universal/ Global/
Population wide
all members in
available
population
At-risk groups
groups considered
at risk for eventual
problems, but who
are not yet
dysfunctional
Groups with
stressful life
events or
transitions
Brown & Liao
1999
Intervention
Selection of effective intervention
according to population and disorder
at hand
Population
Selection of population at risk
© Raija-Leena Punamäki 2007