Abstract
Trauma and trauma-informed care are crucial components for family counselors to know. Considering the recent COVID-19 pandemic, the counseling field is reinforced with this continued need to address trauma. This article will provide an overview of how trauma impacts the adolescent brain, how personality is shaped by trauma, and how integration of neuro-informed and trauma-informed family counseling can help young clients and their families. For practical purposes, this documentation will feature a hypothetical client with the pseudonym “Noah,” to further apply neuro-informed and trauma-informed family counseling for readers.
Keywords
Considerations of the efficacy of neuro-informed care are crucial for facilitating beneficence for all clients and families experiencing various forms of trauma (Montague et al., 2020). The various principles of trauma-related work include safety, trustworthiness, transparency, peer support, collaboration, mutuality, empowerment, choice, and consideration of historical cultural issues (Black, 2006). Neuro-informed counseling also recognizes these principles along with encompassing a unique professional definition. Specifically, neuro-informed counseling, also termed neurocounseling, is the practice of counseling that is informed by neuroscientific principles. This counseling modality includes the notion that behavior and psychological issues have correlating physiological and neurological underpinnings (Beeson & Field, 2017). Neuro-informed counseling also considers systemic influences and can be used alongside family therapy techniques. In fact, several aspects that are involved in neuro-informed counseling and can be involved in family counseling include an emphasis on attachment, interpersonal relationships, and systemic considerations including brain circuitry and environmental factors (Black, 2006; Montague, et al., 2020).
Case Study
As neuro-informed family counseling is considered in this manuscript, please imagine an individual client with the pseudonym of Noah. Noah identifies as a 14-year-old African-American cisgender, heterosexual male. When considering systemic and ecological models, Noah's context will also be described. Noah recently returned to school in person after COVID-19 and has witnessed domestic violence between his mother and her ex-husband. Noah has also witnessed acts of community violence in his larger community system. As the reader may infer, Noah regularly re-experiences past trauma. When considering Noah's familial subsystem, Noah's mother also has a history of childhood physical and sexual abuse. Noah's case, though disheartening is unfortunately one of many clients who have experienced adverse childhood experiences (ACES) and systemic-related traumas. Adverse childhood experiences will be addressed below.
Adverse Childhood Experiences (ACES)
ACEs are considered within a systemic model and have been widely associated with negative health outcomes across the lifespan (Bellis et al., 2019). Since the release of the ACEs study by the Centers for Disease Control (CDC) and Prevention and Kaiser Permanente in 1998, over two decades of research has documented the relationship of ACEs with physical and mental well-being. ACEs include direct harm to children (e.g., abuse and neglect) and indirect harm through living environments (e.g., parental conflict, mental illness, or substance abuse) (Felitti et al., 1998). In the absence of assets and resources such as resilience, self-esteem, and perceived social support, ACEs can translate into chronic stress, leading to physiological and psychological breakdown (Folayan et al., 2020; Perez et al., 2016). Furthermore, at least 44% of children in developed countries and 59% in developing countries had been victims of emotional, physical, or sexual violence, or had witnessed domestic or community violence in the last year (Hillis et al., 2016). Many of these traumas, known as ACEs, are also “strongly partitioned by socioeconomic status and related inequities intertwined with poverty such as, race, gender, immigration status, class, and other axes of social inequality” (Berens et al., 2017, p. 2).
A dose-response relationship exists among ACEs, linking cumulative adversity with increasingly worse outcomes (Bellis et al., 2019; Berens et al., 2017; Cronholm et al., 2015). ACEs highly correlate with an increased likelihood of negative outcomes later in life, including higher levels of adolescent problem behaviors (Bellis et al., 2019; Berens et al., 2017; Bomysoad & Francis, 2020), post-traumatic stress symptoms (Brockie et al., 2015; Kalmakis et al., 2020), substance use (Bomysoad & Francis, 2020; Bellis et al., 2019; Hughes et al., 2017; Brockie et al., 2015), incarceration (Olafson et al., 2018), poor self-esteem (Folayan et al., 2020; Perez et al., 2016), risky sexual behavior (Hughes et al., 2017)
When considering Noah's intrapersonal system, early adversity may become “biologically embedded,” and physiologically alter Noah's brain during periods of high stress (Berens et al., 2017). While substantive problems may emerge during adolescence, this period of development also represents a unique opportunity to modulate maladaptive behaviors and cognitions before they are “inscribed” in the brain's rapidly altering neurocircuitry (Montgomery, 2013, p. 198). Noah's neurocircuitry is his intrapersonal system within his larger familial system. Thus, neurocounseling using family and systemic approaches are best practices for clients like Noah. Efficacy of neurocounseling with adolescence is, in part, described by interventions for working with adolescent personality.
Personality Defined
Personality is another subsystem in Noah's intrapersonal system. Personality is a broad term that is conceptualized as a continuous, biological force that impacts a person's patterns of thoughts, feelings, and behaviors (Branje et al., 2007; Carver & Connor-Smith, 2010). Personality examines what makes people different and, at the same time, what makes them the same (Carver & Connor-Smith, 2010). Personality theory has evolved from the consideration that variance in individuals derive from three factors, listed as extraversion, neuroticism, and psychoticism, to the more well-established notion of the Five-Factor Model. The Five-Factor Model is often referred to as “The Big Five”. Studies examining alternative personality inventories have indicated that tests, for example, the Myers–Briggs Type Indicator can be interpreted as measuring the Big Five (Carver & Connor-Smith, 2010). The Big Five includes neuroticism, extraversion, openness to experience, agreeableness, and conscientiousness. Neuroticism (is labeled as emotional stability when reverse-scored) includes: angry hostility, depression, self-consciousness, impulsiveness, and vulnerability. The facets of extraversion are warmth, gregariousness, assertiveness, activity, excitement-seeking, and positive emotions. Openness categories are fantasy, aesthetics, feelings, actions, ideas, and values. Agreeableness encompasses trust, straightforwardness, altruism, compliance, modesty, and tender-mindedness. Last of the five types, conscientiousness includes competence, order, dutifulness, achievement striving, self-discipline, and deliberation (McCrae et al., 1998).
The Revised NEO Personality Inventory (e.g., NEO PI-R version and NEO PI-3 version) is the scale widely used to measure salient factors of personality with adults and teenagers (De Fruyt et al., 2000). For measuring such a complex structure such as personality, current questionnaires appear quite simple in their construction. However, these seemingly simple tools have been deemed appropriate and valid for what they intend to measure (Herrmann & Pfister, 2013). Scales measuring personality could be used in neuro-informed, trauma-informed, and family counseling practices (Hanna, 2020).
Addressing the Subsystem of Personality Through Neurocounseling
When considering the earlier integration of personality and neurocounseling, Blankstein et al. (2009) wanted to examine why women were predominately disposed to mood disorders. These researchers examined the neurological components of the personality. Zooming in beyond societal implications and likelihood of receiving a diagnosis, these researchers used magnetic resonance imaging (MRI) scans of clinically healthy male and female adolescent brains to measure gray matter volume (GMV) and cortical thickness. Blankstein et al. (2009) found that the medial frontal gyrus (GMV) and extraversion negatively correlated for females. Comparatively, neuroticism correlated positively with cortical thickness and GMV of the subgenual anterior cingulate cortex. For adolescent males, the opposite effect was reported (Blankstein et al., 2009). The regions examined in this study are also associated with social cognition and the processing of emotions. These and other authors pinpoint that these regional and structural differences are some components of sex-linked differences in male/female mood disorders, specifically during the maturation of adolescence (Blankstein et al., 2009). Similarly, Delaparte et al. (2019) found that, for adolescent girls, neuroticism was associated with lower medial orbitofrontal cortex (mOFC) volume. The mOFC is the region of the brain associated with emotion and reward in decision making. Examining the neurological components of the system of a person's personality lends itself to a greater understanding of the interactions between the personality and brain structure. Emphasis on interactions is congruent within a neurocounseling lens, and is also congruent to family therapy approaches, including Internal Family Systems (Schwartz & Sweezy, 2019).
Other Adolescent Neurobiological Considerations
Though exploration regarding neurocounseling and all personality and brain development is essential, these researchers particularized literature regarding adolescent development. Please continue to remember our hypothetical client, Noah, who is only 14 years old. Noah's brain undergoes global changes during this time as he is currently in adolescence. This time of growth represents a pivotal time rivaled only by neonatal development (Montgomery, 2013). During adolescence, Noah's critical functions are stressed, such as emotional regulation (i.e., self-regulation and interactive regulation), judgment, moral reasoning, impulse control, and left hemisphere academic skills (i.e., that are enhanced by a regulated right hemisphere functioning) (Montgomery, 2013; Somerville et al., 2013). Healthy connections between hemispheres form during the maturation of the corpus callosum, a brain structure responsible for coordinating information across the brain. While left hemisphere academic skills can develop without social interaction, healthy right hemisphere development requires positive synchronization with matured brains. Maturing brains are incredibly “plastic,” meaning that they easily change and adapt in response to experience (Montgomery, 2013). Adolescence for all people, including Noah, represents an ongoing reorganization process where prominent neural connections are strengthened and disused neural connections are pruned, or discarded—a process largely shaped by environmental factors including familial-related trauma. Consequently, our client Noah, and his brain are particularly sensitive to stress such as trauma or stress that is involved with childhood trauma (Kim et al., 2018).
Adolescent Neurobiological Consequences of Childhood Trauma
When considering systemic theories, family therapy involves understanding that maltreated adolescents are affected by a system balanced in trauma (i.e., the family in distress). Specifically, from a neuro-informed lens, adolescents like Noah, with or without trauma-related psychiatric disorders, may show reduced brain volumes, with changes observed in frontal, temporal, occipital, and parietal regions, and an overall decrease in gray and white matter volume due to their proximity in a system balanced in trauma (Bick & Nelson, 2016). Perturbations to stability as well as, to Noah's prefrontal cortex (PFC) are particularly harmful, as the PFC is an area that exercises executive functions such as planning, prioritizing, impulse control, cognitive flexibility, and affect management (Kim et al., 2018). Trauma affecting Noah's brain system, including in or around his family system, is likely to provoke event-related cognitive processing, such as rumination, which propagates harmful psychosomatic reactions to stimuli—both malignant and benign (Tedeschi & Calhoun, 2004). Other notable areas of impact for Noah and other clients, could include the cingulate cortex (involved in self-regulation, error detection, and conflict monitoring), the amygdala (i.e., the fear center), the insula (responsible for interoception, or the brain's ability to read internal sensations, and proprioception, awareness of one's body in space), and the hippocampus (i.e., the memory center) (Bick & Nelson, 2016). Brains, like Noah's brain, which are exposed to trauma, demonstrate underactivity among the PFC, the cingulate, and the hippocampus; a dysregulated Insula; and an overactive amygdala (Sweeton, 2019).
Influence of Relationships and Attachment on the Brain System
As referenced in this earlier documentation, comprehensive care should include each neuro-informed, trauma-informed, and family-emphasized practices. Neuro-informed practice, is similar to family systems practices, as neuro-informed practice considers interpersonal attachment and relationships. For children like Noah, interpersonal attachments are met with disruptions and are frequently associated with ACEs. The disruptions in Noah's relationships, attachments, and overall life, all pave the way for nervous system imbalances. The nervous system is a salient piece of Noah's intrapersonal system, as it is responsible for regulating the body's sympathetic and parasympathetic responses—colloquially known as the “fight or flight” and “rest and digest” functions (Sweeton, 2019).
Secure attachment is emphasized in various theoretical orientations including in some family theories, and ensures a homeostatic balance of emotions. Comparatively, avoidant attachment inhibits the parasympathetic nervous system, subsequently compromising one's ability to tolerate high arousal. Additionally, ambivalent attachment excites the sympathetic nervous system and compromises one's ability to tolerate low arousal. Also, disorganized attachment “unpredictably” regulates the system as a whole (Montgomery, 2013, p. 206). Thus, adolescents with a history of ACEs often have trouble coping with past trauma and may even engage in maladaptive coping such as suicidal behavior as an extreme means to regulate emotion and affect (Perez et al., 2016). In fact, as of 2017, suicide was the second leading cause of death for persons between the ages of 10 and 24 years (Istriana, 2020; CDC, 2019), and current statistical data shows this trend continuing (CDC, 2021). As a result, it is critically important that adolescents receive family counseling facilitative of support, stability, healing, and post-traumatic growth (PTG).
Comprehensive Neuro-Informed and Trauma-Informed Family Counseling
Recalling back to hypothetical client Noah, please consider an appropriate treatment plan that fosters trauma-informed and neuro-formed counseling, infused with family therapy considerations. This treatment plan is for conceptualization purposes and is not to be viewed as rigid, definitive, stagnant, or immovable. This example treatment plan is a general template for readers to begin considerations of infusing neuro-informed, trauma-informed, and family counseling practices, as these are all inherently systemically based. Noah's treatment plan may include:
Stage one of Joint Counseling
Psychoeducation with Noah and his mother around trauma and bottom-up approaches, including aiming for an increase in affect regulation, a decrease in hypervigilance, and a reduction in dissociation and reactions to trauma triggers (Sweeton, 2019). Bottom-up approaches (i.e., which change the brain through the body and operate under the same principles as polyvagal theory) should receive priority, particularly due to their ability to de-activate the amygdala (fear center), strengthen the insula (interoception center), and activate the hippocampus (memory center), thereby decreasing hypervigilance, reducing dissociation and reactions to trauma triggers, and increasing feelings of safety (Sweeton, 2019). Bottom-up techniques include progressive muscle relaxation, mindfulness approaches, breathing exercises, and body scanning (Nadal & Skov, 2017). These trauma-related and neuro-related techniques could be used while working jointly or separately with Noah and his mother.
Stage two of Joint Counseling
The following phase of treatment should introduce top-down techniques for Noah and his mother. Top-down approaches change the body through the brain (Sweeton, 2019). Unlike bottom-down techniques, which change the lower, subcortical regions of the brain, top-down techniques change the upper, cortical regions of the brain by deliberately activating the PFC (thinking center) and cingulate cortex (emotion regulation center), thereby improving focus and emotional processing capability (Nicholson et al., 2017; Sweeton, 2019). Top-down techniques include cognitive restructuring and largely overlap with Cognitive Behavioral Therapy or Trauma Focused-Cognitive Behavioral Therapy approaches (Everhart Newman et al., 2018; Sweeton, 2019). Both Noah and his mother would benefit from cognitively restructuring any distortions that have affected both of their intrapersonal and interpersonal systems. Possible helpful top-down approaches could include helping Noah and his mother to reduce trauma-related self-blame (i.e., especially for Noah's mother as a parent), improve self-image, set goals for the future, and to gently challenge negative core beliefs.
In addition to paying special attention to developmental needs, adolescent interventions should also emphasize multidisciplinary treatment, continued reinforcement of family engagement, and building rapport with additional adults. Other systemic-related treatments should include a focus on academics and recreation, as well as prevalent adolescent issues such as self-esteem, eating disorders, anxiety, depression, and self-harm (Brockie et al., 2015). For Noah's mother, additional support can include mothers’ support groups, individual adult counseling, and participation in added psychoeducation related to intergenerational trauma and the body. A counselor may also incorporate bibliotherapy techniques in and outside of paired counseling sessions for both Noah and his mother.
Stage Three of Joint Counseling
After some processing and insight into their presenting concerns for family counseling, Noah and his mother may also later be encouraged to incorporate trauma into a suitable and therapeutically appropriate growth narrative. This stage of counseling would begin as individual counseling and given various therapeutic conditions, Noah and his mother would later reunite for processing of their narratives. This reprocessing would occur after creation and individual reflection of a trauma narrative. This trauma narrative comes from trauma-focused cognitive behavioral therapy (TF-CBT). TF-CBT is the typical front-line approach to individual trauma treatment (Everhart Newman et al., 2018).
Stage Four of Joint Counseling
After initial processing of individual trauma narratives, neuro-informed and trauma-focused family counselors would also help Noah and his mother strengthen their parent–child relationship. When therapeutically appropriate and often after some period of time in counseling, Noah and his mother may be encouraged to reflect on the concepts of resiliency and PTG. While resiliency is generally known in the clinical world as a client's ability to “bounce back,” resiliency is not the same as PTG (Fletcher & Sarkar, 2013). PTG refers to positive psychological changes that develop from exposure to stressful life events (Calhoun et al., 2010; Tedeschi & Calhoun, 2004; Tedeschi & Calhoun, 1996). For Noah and his mother, facilitation of PTG may help continued healing and growth after the ACEs they’ve both experienced.
While research on PTG is relatively nascent, there is growing literature on its application to children and adolescents. Certain cognitions, due to neurobiological development, are available for adolescents that children cannot mirror. Areas of the brain responsible for executive control, for example, which includes affect management and cognitive flexibility, do not develop until middle childhood. In order to instill reportable PTG, youth, like Noah, must be able to express and recognize emotions, both negative and positive, regarding the ACE(s) and have an increased capacity for emotion-focused and cognitively oriented coping. Examples of PTG experienced by Noah and his mother may include a new life philosophy, positive spiritual changes, a renewed appreciation for life, a greater sense of self-understanding and personal strength, and improved social relationships (Itzhaki, 2015; Roepke, 2015; Tedeschi & Calhoun, 1996).
Facilitation of PTG in neuro-informed and trauma-informed family counseling may be important for many reasons. For example, specific personality traits are correlated and increased with the development of PTG, such as; openness to experience, problem- and emotion-focused coping, social support, and environmental characteristics (e.g., gender, younger age, and higher educational level) (Tedeschi & Calhoun, 2004). Other and later efforts may include advocacy. It is important to note that neuro-informed and trauma-informed counselors also reinforce advocacy as societal oppression is another form of trauma that can impact brain development.
Stage Five of Joint Counseling
Other neuro-informed and trauma-informed counseling with Noah and his mother should also further address systemic inequalities, such as racial inequalities that impact children. As previously referenced, Noah is an African-American boy and is impacted, not just within, but also surrounding his family system. Additionally, advocacy that may be salient to preventing and mitigating traumas for clients like Noah and his mother, include advocacy to prioritize access to childcare, parental leave, and mental health services; advocacy to expand family poverty programs; and advocacy to amend criminal justice and immigration practices that separate children from their nurturing caregivers (Ratts et al., 2016). Collaborative trauma-informed services should prioritize integrated supports capable of providing treatment for the entire family structure.
Barriers to Neuro-Informed and Trauma-Informed Family Counseling
When considering the dearth of research identifying usage of each neuro-informed, trauma-informed, and family counseling practices, it is expected that both clinicians and researchers gain increased competence in this interwoven therapeutic consideration (Hanna, 2020).
Additionally, counselors using neuro-informed practices must be competent in a specialized neurocounseling modality. Counselors may gain competence about neuro-informed work by attending workshops from leaders in the neurocounseling field, including Dr. Eric Beeson, Dr. Thom Field, Dr. Lori Russell-Chapin, Dr. Chad Luke, Dr. Laura Jones, and others. One concrete catalyst for learning more about neurocounseling includes reading about the Ten Practical Guidelines for Neurocounseling in the book Brain-Based Clinical Approaches (Field et al., 2017). Similarly, counselors practicing trauma-informed counseling must be competent in this modality. Counselors may attend seminars from trauma-informed clinicians including Dr. Eric Gentry, Dr. Jennifer Sweeton, Dr. Cathy Malchiodi, and others. Counselors may engage in specialized trainings including completion of the certification of Certified Clinical Trauma Professional (CCTP) and others. Additionally, counselors wanting to practice in family counseling must have expertise in this area, as well. As readers most likely already know, counselors can gain this expertise, in part, through engagement in organizations including the International Association of Marriage and Family Counselors and the American Association of Marriage and Family Therapy. Counselors are also encouraged to become fully licensed-eligible counselors and/or fully licensed-eligible marriage and family therapists. Relatedly, counselors using interventions seeking PTG must be familiar with sensitive trauma work including having expertise and certification, such as the CCTP.
Even if proper modifications are applied to best serve clients and their families (i.e., like Noah and his mother), many adolescents lack the financial opportunity to attend treatment. Low-income areas are known for high mental health issues and low access to care (Olafson et al., 2018). As a result, impacted adolescents may only have access to treatment offered through the education system. When specifically considering family therapy, more integration of family-oriented mental health supports within the K–12 system should be considered and introduced.
Lack of access to care is not the only other barrier. Many adolescents, regardless of treatment opportunity, live in households with an abusive or neglectful parent (Scully et al., 2020). Similar instances of ongoing trauma will impact success rates and possibly halt if not reverse ongoing progress of any counseling. Superior systems of intentional family counseling integration may allow family counselors, teachers, or mental health experts to “catch” these adolescents before they lose support and enter adulthood and/or stay in an abusive home. Other barriers also exist and due to lack of research, family counselors should continue to create added awareness about the needs of underrepresented clients, including adolescents in underrepresented families.
Conclusion
This article describes addressing adolescent clients and their families with a neuro, trauma, and family-informed lens. ACEs are capable of biologically embedding seriously maladaptive traits in growing adolescents, especially within at-risk communities. The period of adolescent development represents a unique opportunity for neural reconstruction capable of diminishing ACEs’ otherwise severe and chronic consequences. Resilience and PTG may also play key roles in ongoing research targeted at reducing post-traumatic stress symptoms, such as those generated by ACEs. This topic overview hopes to add valuable insight to the existing literature about adolescent neurodevelopment, trauma impacts, and trauma-informed family work, and promotes the creation of proactive and interdisciplinary interventions. Potential interventions stemming from this synthesis and related research may mitigate and prevent the destructive potential of trauma. Family therapy, traditionally, highlights systemic emphasis and thus, neuro and trauma-informed practices may be well integrated into family-based clinical work. Clients such as, Noah, can ultimately be better helped using comprehensive best practices, including best practices of infusing neuro-informed, trauma-informed, and family-informed clinical work.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
