Introduction

Traumatic childhood events have the potential to impact adult health and happiness (CDC, 2016; Felitti et al., 1998) and may powerfully shape parenting practices (Hambrick et al., 2019; Schickedanz et al., 2018). The intergenerational effect may be particularly pronounced in the context of social marginalization (Choi et al., 2019; Liu et al., 2018; Nurius et al., 2012). This insight has led to the inclusion of assessments targeting adults’ childhood experiences across clinical contexts, including family-based interventions for high-risk children and adolescents (Stob et al., 2019). Despite the face validity, collecting information about parents’ traumatic childhood experiences requires careful consideration (Finkelhor, 2018; Ford et al., 2019; Kia-Keating et al., 2019, Loveday et al., 2022; Rariden et al., 2021). Even though childhood trauma is pervasive (60% in the general population report one or more instances) (DiGiangi & Negriff, 2020), these experiences often remain deeply private. For this reason, being asked about them outside the context of an intimate or secure relationship – where anonymity or confidentiality is ensured, and appropriate emotional support is available– may not achieve the stated goal. Indeed, previous literature suggests that individuals may opt not to disclose the information to retain social desirability (not sharing something that might impact the other’s perception of them negatively) or guard against an influx of painful feelings (see Finkelhor, 2018, for a review of findings). In this instance, asking about traumatic experiences simply yields inaccurate information. For others, being asked about childhood trauma – particularly if it has not previously been named or shared – may be overwhelming to the point of triggering a new traumatic reaction (Feder et al., 2009). Being asked, especially without appropriate preparation, about such deeply painful and private information can feel dehumanizing and increase mistrust in the provider or agency responsible. Those who are tasked with collecting information about childhood trauma may also be left feeling intrusive and unhelpful. In this instance, asking about traumatic experiences is not simply inefficient but potentially harmful for both parties (see Loveday et al., 2022, for a review of concerns). Asking an adult to disclose and explore childhood trauma in the context of their own child’s mental health treatment requires even greater caution.

Indeed, the importance of working actively with parents is well established (see Novick & Novick, 2011, for an in-depth introduction), and exploring parents’ childhood experiences may be highly relevant, especially in the context of examining or improving parenting practices (Loveday et al., 2022; Whitefield & Midgley, 2015). Adults who parent are deeply impacted by their own early life experiences and particularly the way they were treated by their own caregivers (Schickedanz et al., 2018). The specific impact is often hard to spot, as relational patterns over time become second nature and implicit to our own self-experience: we do what “feels natural”. The link between adverse childhood experiences and parental reflective functioning or mentalizing - i.e. parents’ ability to understand the child’s behavior in terms of mental states (Allen et al., 2008) – has received considerable attention (see Dollberg & Hanetz-Gamliel, 2023 for an in-depth review of findings). Subsequently, engaging parents in exploration about their childhood experiences has become common practice in certain child and adolescent outpatient treatment contexts and particularly in family-based, attachment-informed and mentalization-based interventions (e.g. Circle of Security, Mentalization Based Treatment for Children and Families (Midgley et al., 2017; Malberg et al., 2023), Minding the Baby (Slade et al., 2023) and psychodynamic child psychotherapy (Whitefield & Midgley, 2015).

In the US, the most vulnerable children and adolescents – i.e. those who are facing concurrent acute mental health symptoms, familial or parental instability, poverty and social marginalization – are typically offered intensive, home-based treatment (IHBT) (Moffett et al., 2018). IHBTs represent a unique level of care, a step down from inpatient treatment designed for those in need of more intensive, flexible support than can be offered in regular outpatient practice. Despite the high prevalence of trauma among both youth and parents in this group (Stob et al., 2020) and the purposeful inclusion of the entire family in the intervention, parents’ childhood experiences and the impact on current parenting practices are not routinely explored in IHBTs (Bruns et al., 2021).

The Intensive In-home Child and Adolescent Psychiatric Service (IICAPS) is a large, well-established, structured intervention engaging high-risk families in Connecticut, USA. The children (aged 3–18) and families in IICAPS are typically in acute crisis and present with a wide array of severe and highly comorbid psychological difficulties. Clinical services are delivered over a six-month period in the home (or wherever the family feels comfortable) by a two-person team where one works individually with the child, one works individually with the parent, and all come together for family sessions (three sessions weekly in total). See Woolston et al. (2007) and Stob et al. (2019, 2020 and, 2023) for additional descriptions of clinical practices in IICAPS.

Following decades of clinical experiences with the complex, chronic and multigenerational structures of developmental trauma and psychosocial vulnerability facing these families, the Important Childhood Events (ICE) tool was adopted into clinical practice in 2015, to anchor the highly individualized psychotherapeutic work with parents. Since the introduction of the ICE, additional clinical tools have been developed and incorporated to support parents, children, and clinicians in identifying and targeting family dynamics that perpetuate trauma (see Stob et al., 2019, 2020 and, 2023) In the present paper, we will describe in depth how we engage parents in exploring their own painful and resiliency-building experiences in childhood in the context of an intensive, home-based intervention targeting very high-risk children and families. In the best of cases, this process allows for a deepening of the therapeutic relationship between the parent and clinician and fosters increased empathy and mentalizing in both parties. At other times, negative affective reactions in the clinician and/or parent may result in superficial, scripted, or disorganized responses that may impede treatment progress or cause the therapeutic relationship to collapse. Our aim is to contribute to the implementation of trauma-informed, mentalization-based clinical practices with high risk populations by providing detailed descriptions of therapeutic work. We do this by operationalizing steps in the therapeutic process to prepare both parent and clinician for such difficult conversations, and by describing clinical vignettes which illustrate how to mentalize and repair following avoidant or dysregulated parent responses. While we are referring specifically to practices within the context of IICAPS, we hope that this will provide a guide for practicable application in other contexts.

Working with Parents’ Childhood Experiences in Intensive, Home-Based Interventions

Since the start of IICAPS in 1996, clinical and empirical data have pointed to the importance of parents’ childhood experiences in their own parenting (Stob et al., 2019, 2020, 2023). To capture both traumatic and resiliency-building experiences in parents’ early lives, we developed and implemented the Important Childhood Events (ICE) tool in 2015. We incorporated relevant items from several published versions of the ACE scale, and a review of available literature describing important resiliency-building experiences in childhood (Masten & Barnes, 2018). The scale thus retains its accessibility and ease of scoring (yes/no), while expanding to include non-adverse experiences found to predict the development of resilience. See Table 1 for the final list of items.

Table 1 List of items in the important childhood events scale
Full size table

In IICAPS, the purpose of asking about parents’ positive and negative childhood experiences is ultimately to engage them in a process about how they perceive and parent their child. Simply collecting responses to the ICE scale is not the goal. Rather, it is a standardized clinical tool used with the aim of.

  1. 1.

    Deepening the therapeutic relationship: building trust by helping the clinician understand/empathize with/mentalize the parent and making the parent feel seen.

  2. 2.

    Helping the parent acknowledge their own important childhood experiences and thereby foster a more cohesive self-narrative.

  3. 3.

    Modeling exploring meaningful experiences, so that the parent can safely examine the child’s important life events with them.

  4. 4.

    Supporting the parent in acknowledging how their own childhood experiences may have influenced their parenting and, ultimately, the child’s experiences.

This understanding informs our entire approach to the ICE and is continuously emphasized in training and supervision. What follows represents our current understanding of how to use the ICE to bolster parental self-reflection, expand parental perceptions of the child, and foster more sensitive parenting.

Training and Supervision: Preparing the Clinician

The essence of trauma is the experience of being overwhelmed: a situation that overrides the individual’s capacity to cope (Masten & Barnes, 2018). Consequently, it is natural to feel avoidance when asked to remember one’s own trauma or to inquire about others’ traumatic experiences. Preparation and support are needed to overcome avoidance and work both gently and effectively.

Preparation and Training

Knowledge.

The clinician needs to understand why we ask parents about their childhood trauma and how it anchors the treatment. This is usually a gradual process, which can start with formal training but requires continuous personal engagement.

Lived Experience and Empathy.

Engaging parents about painful life experiences requires clinicians to be attuned and sensitive. Many clinicians spontaneously grasp how vulnerable and painful it can be for a parent to tell someone who is there to help them be a better parent about some of their most painful memories. We have found that it can help clinicians be empathic and attuned to either answer the ICE questions themselves or be asked to imagine doing it.

Addressing Biases and Resistances.

After having experienced or imagined themselves as the respondent, it can be helpful to role play sitting down with a (specific) parent to ask about childhood experiences. We ask clinicians what comes up for them, whether it felt irrelevant or inappropriate, overwhelming, or even dangerous. We ask them to consider how they are likely to respond to a parent who is dismissive or becomes overwhelmed and how they typically respond to strong feelings. Talking through different scenarios may help the clinician prepare for different responses and lower the threshold for getting started. Practicing different ways to word explanations and questions can be helpful, emphasizing that each situation will require an attuned and adapted response.

Supervision

Make a Plan and Stick to it.

There is always a lot going on in therapy, especially for families who are facing frequent crises. Asking parents about their childhood experiences is a priority and making a plan to complete the ICE can create necessary scaffolding.

Receive Validation.

Listening to trauma histories can be overwhelming, disorganizing, and exhausting and clinicians can react in different ways, as described in the vignettes below. Having discussed this prior to starting the work can give a clinician pair or a clinician/supervisor dyad important grounding for spotting strain. Having space to process personal reactions and having those reactions validated can reduce emotional burden and thereby increase the clinician’s capacity to mentalize the parents. This mirrors how parents often are better able to empathize with and mentalize their children once their own needs for validation and understanding have been met (Midgley et al., 2017). Thus, supervisors can model this behavior. It may be wise to check in explicitly with clinicians who are in the process of gathering information on the ICE.

Get Curious.

Working with parents who have exposed their children to danger or who have not been able to support them sufficiently can be extremely taxing. Many clinicians empathize strongly with the children and may become resentful or harsh in their perceptions of parents. Although understandable, this may impede the clinician’s ability to engage in attuned and empathetic ways with the parent. To overcome this, it may help to spend time in supervision mentalizing, i.e. actively imagining what is going on with the parents. The clinician can be prompted to imagine who the parents were as kids, teenagers, or young adults, how they’ve experienced the world and how it’s impacted their parenting. Wondering “out loud” why a parent behaved the way they did can lead the clinician to consider what they know about the parent’s history. IICAPS is well set up for this because there are partner clinicians, which means that two perspectives are always available.

Working with Parents

Laying the Groundwork with the Parent building a relationship and a shared understanding of why childhood experiences matter.

Getting to the point of being able to safely explore important childhood events with parents often requires substantial efforts. For many parents, it is necessary first to understand why their own childhood experiences even matter in the context of their child’s mental health treatment. Tempting as it may be, we have found that explaining this in theoretical terms is not an effective strategy. Firstly, front loading with abstract and complex information in a situation where the family is in a crisis can feel irrelevant or confusing. Secondly, suggesting that there is a link between a parents’ worst experiences and their child’s struggles can feel shaming. Rather than explaining, we have found that the most powerful way to communicate that the parent and their experiences matter is to focus on building a strong relationship which includes taking an interest in their history (see the description of John in the vignette below). To engage with the potentially overwhelming feelings related to traumatic events parents (and clinicians) need to feel safe enough. This is especially important as these events have often not been shared. Without a trusting relationship, it may be possible to gather facts, but the emotional experience that is associated with them and is the target of the therapeutic effort is often not available. Building a strong therapeutic alliance is complex and necessitates attunement and sensitivity on the part of the clinician. Here are some key aspects of this work that is emphasized in IICAPS.

Demonstrate a Benign but Keen Interest in Parents as Individuals with their Own Needs.

To many parents, it will not be obvious why their childhoods (or they themselves) are relevant in the context of a child or family-focused intervention. In the first session, the parent-clinician may be introduced by explaining that “parents are a big part of their kids’ lives, and we want to get to know you”. The initial sessions with the parent are exploratory and focus on getting to know them in their day-to-day life. Inconspicuous as this may seem, this form of interaction may be in stark contrast to parents’ experiences with mental health professionals and may be a potent way to demonstrate interest and acceptance. A central goal for this phase is to develop a way to work together and a feeling of shared purpose.

Validate Struggles in Life and Parenting.

For adults who parent, feeling competent in their parenting deeply impacts self-perception and feelings of self-worth. Many parents in IICAPS feel very little agency in their relationship with their children and many have experienced being blamed for their child’s struggles (Stob et al., 2020). Asking about difficulties and acknowledging how hard it has been for the parent communicates that the parent is worthy of understanding and deemphasizes blame. This mirrors the stance we hope parents will adopt when their children are in difficulty. As demonstrated in the second vignette below, however, this is not always straightforward as validation can come across as being patronizing or confusing. Nevertheless, we consider this a crucial developmental experience to be normalized (over time) and an essential form of interaction for the parent to engage in with their own children.

Emphasize the Importance of Feelings, Relationships, and Past Experiences.

Often, parents’ childhood experiences come up spontaneously (such as with Joyce in the third vignette). If not, clinicians may ask directly about the context of the parents’ life, either in a conversation or by using a semi-structured tool such as a timeline, a three-generational genogram or parts of the adult attachment interview (Steele & Steele, 2008). Having a designated activity can be particularly helpful in situations that are marked by frequent crises (where looking at the past may feel less urgent than managing an ongoing situation) or in situations where the parent or clinician is struggling to find the words or experiencing high levels of anxiety (external scaffolding). These tools do not specifically inquire about traumatic events but invite the parent to describe what their life looked like at a certain time and the important people in it. If asked, the clinician may say that they are interested in these experiences because it may help them understand the parent better. For some, this may be a brand-new notion, triggering a multitude of possible emotional responses. Crucially, how the clinician responds to the feelings and experiences the parent shares will influence the quality of the relationship. Being able to mentalize the parent and offer empathy in a way that feels appropriate to them is particularly important in moments like these.

Asking Specifically About Important Childhood Experiences (ICE)

Framing.

By the time the clinician decides to explore the ICE, the therapeutic relationship should be well developed, and the parent will have had several experiences exploring feelings, relationships, and past experiences. The clinician can choose to suggest the week before that they want to return to the parent’s childhood and make sure that there will be enough time and privacy to allow for this conversation. On the day, we suggest introducing the ICE questions by tying them back to a previous conversation or activity (“I’ve been thinking about what you shared before and was wondering if we could return to it.”).

Asking about Traumatic Events.

The ICE questions may be presented to the parent as a questionnaire or in a more conversational manner. In many cases, the exploration of these events occurs over several weeks, marked by a gradual deepening: from describing facts to relating emotional experiences. Parents connecting with their own emotional experience as children and how others supported them at the time is the main purpose of this activity in IICAPS. A clinician may start the conversation more broadly (“What was it like when you were growing up?”) and follow up with specific questions (e.g. “You said that your mom had a drug problem. What was that like?”). Using the timeline or genogram may be helpful to anchor the conversation (so have them available).

Asking About Resiliency-Building Experiences.

The clinician will need to determine whether to begin by asking about traumatic or resiliency-building experiences, most likely balancing the two across multiple conversations. As a general introduction a clinician may ask “I was wondering if we could talk about some of your happiest memories, what got you through”. Sometimes, it is appropriate to segue from a painful experience to a source of resiliency (e.g. identifying someone who was there for the parent at the time, acknowledging an adaptive and efficient coping strategy, exploring what they thought about themselves). The clinician should be very aware of their own need to find a silver lining to regulate painful or overwhelming reactions to hearing about the parent’s trauma. It can be helpful to keep in mind that the overarching goal is getting to know the parent better and to help create an expansive and coherent narrative of their childhood, not give abstract meaning to or relativize experiences most would never want to have.

Troubleshooting: it’s All About Co-Regulating.

Because the purpose of the ICE tool is to help parents engage with their own important childhood experiences, helping to regulate emotional activation is a key task for the clinician. Parents differ greatly in terms of their emotional regulation profiles and interpersonal styles, and those who have already spoken about or processed their experiences may approach the topic differently from those who have never shared the information. In the following we will share some experiences we have had working with parents who react in different ways to questions about childhood experiences. The focus is on helping parents be emotionally engaged without becoming dysregulated, providing active support to maintain optimal regulation. In all these cases, the way the clinician responds to the parent’s struggle can become a potent model for engaging with difficult feelings and building trust. This experience of co-regulation (i.e. modulating the intensity of emotional activation through interacting with another person) is far more valuable in the context of the overall treatment than getting accurate responses to the ICE items, as this is what we are hoping to help the parents do in turn for their own children.

Working with Parents who Seem Disengaged, Give Shallow, Brief or “Scripted” Responses.

There can be many reasons why a parent may seem checked-out or emotionally disengaged and it is important to understand what is going on. Parents who have never shared their childhood experiences may lack the language to describe their feelings and may need the clinician to actively imagine what it may have been like for them (“lend words”). Parents who have been in treatment before sometimes give seemingly reflective but intellectualized responses to ICE items (missing the “feeling”). They may benefit from being asked detailed questions, such as focusing on bodily perceptions and emotions (heightening activation).

Working with Parents who Seem Disorganized, “Triggered” or Dysregulated.

Some parents, when asked to describe important childhood experiences appear emotionally triggered (angry, irritated, restless), some are flooded with intrusive thoughts or images to the point of appearing dissociated, lose their ability to mentalize or act out. In these instances, our experience is that offering help to organize the information (slowing down, making links, validating), suggesting grounding activities (going for a walk, do a task) or taking structured breaks can be effective (lowering activation).

A note on Trauma-Informed Therapy, Culture, Language, and Power Asymmetry.

The people who turn to IICAPS for help with their children and family dynamics have often not only experienced discreet instances of (individual) trauma. Many belong to communities that have suffered systemic oppression and marginalization for generations and are facing ongoing structural racism and poverty (Kia-Keating et al., 2019). Seeing as the capacity to mentalize is acutely impacted by stress, acknowledging overwhelming life circumstances is crucial context for understanding parents’ reactions. Furthermore, being asked about childhood trauma by a person who is perceived to be in power (either by virtue of their title, profession, or race) can trigger several reactions (Fors, 2021). For some, exploring personal painful or shameful life experiences (particularly as a parent) can feel demeaning, reinforcing stereotypes about who needs help and who is “broken”. In addition to the asymmetry inherent in therapy (where one person is defined as the helper and the other in need of help), the power differential associated with education, class or race may decrease trust and spark loneliness or self-hatred. For people who are facing massive, ongoing systemic and multi-generational trauma, talking about personal experiences of physical or emotional abuse or neglect can feel irrelevant (“white girl sh*t”). The clinician should actively work to understand and empathize with this reaction and IICAPS specifically addresses issues relating to current socioeconomic status. Rather than shying away from the topic of personal childhood experiences, the clinician should aim to support the parent’s feeling of agency through a better understanding of their own reactions (not a sign of “being crazy” but possibly natural responses to overwhelming circumstances) and even the experience of “breaking the pattern” of intergenerational trauma (being mindful of emphasizing that this is near impossible to achieve alone). Clinicians may want to stay clear of jargon and even the word “trauma”. For some, this word denotes something pathological, emphasizing (incorrectly) that something is “wrong with them”. Simply communicating an interest in the parent’s life and past can suffice.

The Aftermath.

In addition to helping the parent and clinician formulate a more coherent narrative about the parent’s childhood experiences, increasing relational trust and empathy, understanding a parent’s reaction to the conversation can be very informative for the therapeutic work. Indeed, it can be useful to keep in mind that the way the parent reacts to questions about their own painful experiences can parallel what the child sees when their parent is triggered. As professionals, we can (sometimes) understand that underneath what looks like anger or rejection is psychological pain, but this may not be obvious to the parent (or the child). Talking about the experience after the fact can be useful to shed light on whether the parent reacted in a way that is typical for them. This can be the foundation of tying the parent’s experience in with that of the child (see paper on the Family Cycle used with parents in Stob et al., 2020). We want to avoid the parent feeling like they were responsible for their own trauma or for any impact on their child.

In some cases, the work with the ICE can shed light on a parent’s own need for mental health treatment. For parents who have had painful experiences with mental health care professionals or institutions, it can be useful to have specific contacts and facilitate the relationship with the new therapist. In some, rare instances, parents drop out of treatment after having explored traumatic experiences with the clinician. Whether or not the two are causally linked, this can be extremely difficult for the clinician, sparking feelings of guilt and concern. In these instances, it is crucial for the clinician to be able to process the situation with peers and supervisors, simultaneously trying to learn from and accepting the outcome.

Clinical Vignettes: Simultaneously Engaging with Negative and Positive Experiences

Vignette 1. Working with Avoidance

John is a 40-year-old white male business owner and divorced father of three who came to work with IICAPS through his middle child, Emily, 13. She was referred to treatment because the family struggled to handle her aggressive outbursts and running away. It soon became clear that part of helping Emily manage her strong feelings would be bolstering her relationship with her dad.

As the parent-clinician, I quickly sensed John’s ambivalence about therapy. In family sessions he seemed deeply committed to helping his daughter feel better. However, our relationship was slow to build. John missed several sessions and although he remained cordial and on-topic, direct questions about how he was feeling appeared to make him uncomfortable. In parallel, I noticed my own growing dread and un-characteristic hesitation about getting too close. The weeks flew by. Despite my hesitation, I decided to propose going through the ICE tool to “talk about important experiences growing up that helped shape him.” He acquiesced, but I wondered if he was simply “going along with protocol”.

We met in John’s living room while the child clinician met with Emily in the yard. John endorsed several difficult childhood experiences (parental separation, transitioning between homes, and experiencing parental fighting) but when I asked him to describe how he had felt during moments or how he had related to his caregivers he gave only short descriptive statements. “I know they were doing their best” and “I always had everything I needed.” Several times he commented that his negative experiences had taught him valuable life lessons. “What doesn’t kill you makes you stronger,” he said, “I learned to be responsible and rely on myself.”

Later that week, my supervisor invited me to imagine what it may have been like for John to experience his parent’s fighting, separating, and living in different homes, all the while telling himself that he should not have feelings about it. She suggested I approach his adversity from the standpoint of the messages he got about his feelings and how he learned to cope, instead of focusing on the specific events. During our next session I asked John if we could return to his idea that “what doesn’t kill you makes you stronger.” I asked John where that message came from and how early he remembers saying it to himself. John paused for a while. Eventually he said, “I guess it came from my Dad,” sharing images of a respected but distant and sometimes intimidating father. Keeping the resiliency questions in mind, I inquired about how other important people made him feel. Right away, John remembered several adults who had been there for him when he needed support and he described with a lot of humor and humility how he had discovered his talent for athletics and math. Suddenly, John’s descriptions were vivid and detailed, and I noticed him getting emotional when he talked about how his football coach had taken on an important role for him when his dad left the family. “I don’t know where I’d be without him,” he said, thoughtfully, leading us into a conversation about being seen and expressing emotional needs. John described the loss of one attachment figure through the lens of finding another and it became clear to me both how important being a good father was to him and how worried he was about his own absence.

In the months that followed, both John and I referenced his discomfort with painful feelings and how his positive experiences having his feelings validated by adults other than his parents impacted him. This helped us examine his approach to Emily and how avoiding versus validating feelings impacted her. John’s love for Emily was so apparent to me and having observed how difficult it had been for him to share painful experiences helped me to support him in expressing both his affection for her and his remorse directly to her during family sessions.

Vignette 2. Space and Repair in Response to Dysregulation

Christina was a 32-year-old white female who struggled with unemployment and had recently been in recovery for opiate addiction. She came to work with IICAPS via her 16-year-old son Joseph, who was referred for debilitating depression and anxiety, and a history of aggression primarily directed towards his mother. Christina blamed him for his difficulties, often calling him names and angrily reminding him that she was only in treatment because of him. It was a high conflict situation, and multiple providers wondered if Joseph would be safe remaining in the home.

My initial meetings with Christina left me with an undifferentiated feeling of overwhelm: intense but vague. Although she was keen to receive more support for Joseph, Christina appeared disengaged, guarded and highly critical. Characteristically, in an activity designed to help family members identify which feelings were ‘safe’ to share with others, Christina declined to participate, expressing that she never shared her feelings because it gave people “something to use against you.” I understood that I would need to move slowly and focus on building trust with Christina to have any hope of helping her make relevant links between her own life experiences and her parenting. However, perplexingly, validating her struggles often seemed to escalate her complaints about Joseph and inviting her to take his perspective usually led to the conversation shutting down. I needed more context for understanding her reactions and – despite my apprehension – suggested to Christina that we look at the ICE together. Mindful of her seemingly strong emotional activation and difficulty regulating (shutting down, storming out, becoming aggressive), I wondered if physical movement could help us remain connected but safely distanced. I was relieved when Christina agreed to go for a walk to pick back up our conversation about her life experiences.

We met on a blistering day in July. The neighborhood was quiet and tree-lined, suburban; our walking provided privacy. I had thought a lot about where to start. Having referenced multiple times how much harder she had it growing up than her son’s current circumstances, I guessed that Christina had many painful memories. Although these seemed imperative to discuss, I worried that exploring resiliency after adverse experiences could feel hollow: saying no to a RCE question after confirming many ACEs seemed only to put a fine point on a painful loss. With that in mind, I chose to start with Christina’s resiliency building experiences, referencing what she had shared – in passing and with apparent pride - about having managed on her own from middle school onwards. Christina answered “yes” to three of ten resiliency questions: “having things she felt she did well”, “being successful in school”, and “figuring situations out on her own”. But all came with caveats. Although she did well in school early in life, she stopped attending regularly by 13, and had to figure things out on her own due to parental neglect. As she launched into descriptions of physical and emotional abuse endured from parents and older siblings, I noticed her speed up and gesticulate with her hands in front of her body. “They were assholes. I had to take care of myself.” she added, curtly, before falling silent. For Christina, the resiliency questions seemed to recall the ways her attachment figures had not met her needs. I wondered what she was thinking about and tried to help her elaborate on the feelings connected to her memories. Her responses became shorter, and her tone more frustrated. I worried she would shut me out again, but I pressed on, hopeful that we could connect over her resiliency. “It sounds like you handled a lot that kids shouldn’t have to deal with”, I said and immediately regretted what I feared was a chipper tone. She was quiet for a few seconds, then stopped and turned towards me, looking angry. “Why do you want to know all this shit?” she asked, " It’s him you should be fixing!” I went numb, mind reeling. I tried to validate her experience, stating, “I know this is difficult, I appreciate you trying to be honest with me.” She scoffed loudly and told me to ‘fuck off’ and that I was clearly “on Joseph’s side.” I remained rooted to the spot as she took off.

The following night Christina finally answered the phone up after I had called twice. “Thanks for picking up” I said, adding that I had wondered about how she was after what happened the day before. “Should I have understood that you needed a break?” “Nah”, she said, “I just hate talking about that stuff”. “I get that”, I said, adding that I had learned some very important things about her from our talk, namely that she prefers to figure things out on her own and pull away when others – including her adolescent son – become overwhelming. “You got that right”, she added and agreed to meet again.

I went to supervision feeling mixed emotions. Talking directly about Christina’s childhood trauma seemed to have triggered her deeply and, in the moment, she responded by becoming aggressive and retreating; a familiar pattern for her. Yet, she appeared to have used her knowledge about me and our relationship to calm down and decide to reengage. The experience with the ICE emphasized to me the extent of Christina’s trauma and framed her current reactions in the context of fighting for survival. Importantly, it brought her past and personal style onto the therapeutic surface and both she and I were able to reference her need for autonomy and tendency to withdraw both as strengths and obstacles in situations that came up with Joseph.

Vignette 3. Recognizing and Bolstering a Reflective Stance

Joyce was a 61-year-old, recently retired African American female who enjoyed keeping active and spending time with her grandchildren. She came to IICAPS via her 14-year-old granddaughter, Imoni who struggled with suicidal thoughts and self-harm. Imoni and her older sister had been living with Joyce fulltime for two years in a foster kinship arrangement. I spent the first several weeks with Joyce, looking through family photo albums and walking together in her cherished yard, learning about her adult children and grandchildren, with whom she had close relationships. I was deeply moved by her memories as a child of longing for both a garden and a family and it was obvious that she took immense pleasure in being able to provide both for her grandchildren. I was implicitly aware that spending some time in silence with her as she talked to me about her flowers and her garden ornaments was meaningful for her and cultivated her trust in me. I was struck by how consistently grounded and reflective she seemed, which led me to ask about her past therapy experiences. Joyce acknowledged that she had been in therapy for several years following her adult son’s (the father of the client) psychotic episode and subsequent arrest. She identified this as a crucial step in understanding and accepting her son’s mental illness. While she did not indicate that she had used that therapy to process her own childhood experiences, she readily accepted my proposal to complete the ICE and surmised that, “It certainly has a lot to do with why I’ve taken in these girls.”

We sat down to complete the ICE on a balmy fall day on her patio. The week before I had prepared her for a discussion about important experiences that she felt had shaped who she was as a person, as a parent, and as a grandparent. In this case, the measure was more of an afterthought and as a clinician I was able to weave in the direct questions seamlessly.

Joyce spoke about the first part of her life as something to endure until she could get out. Her mother’s boyfriend drank frequently and was violent towards everyone in the household (she answered Yes to questions about emotional abuse, physical abuse, parental separation, parental substance use, and exposure to interpersonal violence). Joyce and her mother argued frequently. She lived in a constant state of fear and anger which culminated in being thrown out of the house at age 13. She described this as a huge betrayal and seemed to avoid going into it by stating, “But I moved on and got over it.” I made eye contact and asked her if she would go back and describe to me the day that her mother kicked her out from start to end. In contrast with the easy flow of our previous conversations, Joyce struggled to find words to describe her emotional experience, ultimately settling on rage and emptiness. “The worst part was when she just went cold and told me to leave.” Wiping a tear from her cheek, Joyce reflected that it felt like her mother had abandoned her, answering Yes to “did you feel that no one loved you.” “Thankfully I had somewhere to go”, she said. She described the second part of her childhood as her “saving grace” and spoke of the warmth and acceptance she felt from her boyfriend’s mother and sisters.

Joyce stated that she always knew that she “deserved better” and that she was desperate for her granddaughters to feel that they were worthy of love and affection despite their painful life experiences. I reflected to her that it seemed that the most painful event from her childhood was also what she felt had saved her from the life that most of her siblings who had stayed in the home had. She absorbed this and connected it to her grandchildren. She said, “And that’s my hope for them. That life with me can be a second chance.”

Leaving Joyce’s house that day, I was struck by how she was able to describe her relationships and acknowledge the impact that they have had on her. I found myself feeling renewed by the session.

Conclusion

Childhoods matter and engaging with parents’ own experiences can be a potent mechanism of change in family-based interventions, leading to meaningfully improved parenting practices. Reaching this ambitious goal requires structured, sophisticated psychotherapeutic work in a safe and supportive setting. In this paper, we have described strategies informed by mentalization-based and trauma-informed practices, to engage parents in exploring their own positive and negative childhood experiences in the context of an intensive, home-based treatment program with extremely vulnerable families. This work has evolved over time and continues to do so as our understanding deepens. We hope that our experiences with a highly stressed group of children and families living with complex and intergenerational trauma can shed light on the intricacies embedded in doing this work, with possible translational value to therapists in other settings and primary health contexts as highlighted in recent publications (Finkelhor, 2018). Traumatic events can never be undone or erased but their impact can be mitigated. Working with a parent’s childhood experiences enhances mentalizing and can be a step towards breaking cycles of trauma and adversity in the parent-child relationship.