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 Table of Contents  
CASE SERIES
Year : 2022  |  Volume : 2  |  Issue : 1  |  Page : 17-20

Using innovative narrative therapies with children who witness intimate partner violence


1 Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
2 Dr. BR. Ambedkar State Institute of Medical Sciences, Sahibzada Ajit Singh Nagar, Punjab, India

Date of Submission04-Dec-2021
Date of Decision24-Jan-2022
Date of Acceptance24-Jan-2022
Date of Web Publication25-Feb-2022

Correspondence Address:
Dr. Prahbhjot Malhi
Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ipcares.ipcares_354_21

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  Abstract 

Background: Intimate partner violence (IPV) is a form of abuse in which one partner causes physical, psychological, or sexual harm to the other, in the relationship. Exposure of children to this kind of domestic abuse is quite common in India, though not openly discussed. The management of children who present with functional somatic symptoms (suspected to be psychogenic in nature) is extremely challenging, especially since the history of IPV is not easily forthcoming. This case series highlights the evocative power of trauma-creative narrative interventions, such as poetry writing and story-telling, that help children express their fears and distress in a safe environment. This in conjunction with other modalities of management helps in their healing. Clinical Description: We present three children presenting with various functional somatic symptoms belonging to dysfunctional families. Comprehensive in-depth interviews, psychological assessment, and kinetic family drawings helped us assess each case, elicit the history of IPV, and understand the nature of the individualized fears and distress being experienced. Management and Outcome: The primary interventions used were creative narrative interventions such as asking the children to draw, write poems, and/or tell stories about their family and the situations they were experiencing. This helped them express their feelings of helplessness and latent anger arising from witnessing these violent events. Facing their fears in a safe environment resulted in successful resolution of somatic symptoms of all the three over time. This healing was reflected in the change in expressions via the art, poems, and written/oral narrations. Other strategies like provision of psychoeducation, highlighting the connection between symptoms and the underlying trauma, referral for marital counselling, and improving social support were also used. Conclusions: Pediatricians should have a high index of suspicion of the possibility of psychosomatic conditions when their patients display inexplicable manifestations that do not fit into any recognizable clinical phenotype, either by description or after investigation. These children and adolescents should be referred for a psychological evaluation and further eclectic management. The use of creative narrative therapies in conjunction with other modalities can lead to successful resolution of functional somatic symptoms.

Keywords: Creative interventions, functional somatic symptoms, kinetic family drawing, psychosomatic


How to cite this article:
Malhi P, Bharti B. Using innovative narrative therapies with children who witness intimate partner violence. Indian Pediatr Case Rep 2022;2:17-20

How to cite this URL:
Malhi P, Bharti B. Using innovative narrative therapies with children who witness intimate partner violence. Indian Pediatr Case Rep [serial online] 2022 [cited 2022 May 27];2:17-20. Available from: http://www.ipcares.org/text.asp?2022/2/1/17/338493

Population-based national-level surveys indicate that exposure of children to domestic abuse and violence is pervasive in Indian society. For example, a national study on child abuse reported that 69% of the study population had been physically abused, and among 89%, the perpetrators had been their parents.[1] Intimate partner violence (IPV) is a form of domestic abuse defined as a pattern of behavior used to gain or maintain power and control over an intimate partner that causes physical, psychological, or sexual harm to those in that relationship. Children can be exposed to IPV at home either by actually witnessing such events or even overhearing the associated sounds of discord.[2]

There is a plenty of evidence that indicates that traumatic experiences in childhood can have a long-lasting deleterious effect on the physical and psychological well-being of children and adolescents. This includes posttraumatic stress, reduced coping abilities, insecure attachment, and psychosomatic symptoms, all of which can continue into adulthood.[3],[4] Creative narrative interventions, i.e., role play, drama therapy, poetry writing, story narration, and bibliotherapy-the use of books, when combined with other approaches like counseling and psychotherapy, have demonstrated considerable success with traumatized and chronically ill children.[5] The abstract medium of narrative therapies provides a healing experience by facilitating the articulation of underlying painful emotions, supporting self-expression, and validating one's emotions. Narrative therapies may also be the primary form of communication by the child with the therapist. Since poems and stories can be written in the third person, they provide a safe medium for disclosure of traumatic memories and sharing personal issues. This helps professionals in understanding the children's problems vicariously.[5],[6]

In this case series, we highlight the evaluation of three adolescents belonging to dysfunctional families, who presented with various functional somatic complaints and the successful effect of their management using narration therapy in addition to other modalities. Our main aim is to sensitize and increase awareness of clinicians regarding the existence and importance of such services.


  Clinical Description Top


Family 1: AS, an 11-year-old boy, was referred to the child psychology unit for symptoms of vomiting, abdominal pain, and easy fatigability for three months, on the suspicion of the treating unit that these were psychogenic in nature. Prior to the present evaluation, parents had taken multiple medical consultations, the child had undergone several investigations, and was prescribed various medications, without any symptomatic relief. The child belonged to an upper-middle-class family, was the elder of two siblings, both the parents were graduates, and the father was a professional photographer. The parents reported that AS was shy, academically bright, and enjoyed school, but the recent incapacitating symptoms had led to frequent absenteeism from school, with a subsequent decline in academic performance. The child had also become increasingly withdrawn and fearful and often talked of death.

A comprehensive psychological evaluation of the child was undertaken, comprising several psychological scales and tests. This included the Pre-adolescent Adjustment Scale that assesses a child's adjustment at home, school, with peers, and teachers, and the Kinetic Family Drawing Test. In the latter, children are instructed to draw a picture of their family, including themselves “doing something.” The underlying assumption is that the addition of movement to an otherwise static drawing helps to understand the child's attitude toward other family members and the quality as well as dynamics of interpersonal relations within the family. In this particular case, it was obvious that there was a significant marital discord that was disturbing the child [Figure 1]. These drawings helped AS to open up about the situation at home, that had not been forthcoming from the parents till then. During the narration of his fears and distress at witnessing the unremitting parental conflict, he revealed that witnessing such events made him literally “sick to his stomach.”
Figure 1: Kinetic family drawing made by AS with narrative

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Family 2: DP, an 11-year-old boy, was referred for a psychological consultation for symptoms of non-specific pains at multiple sites including chest pain, headache, and pain in the legs for the last 6 months, for which no medical cause could be ascertained. The mother was extremely worried, especially since the child was an excellent basketball player, and the family (including the child) were keen that he should pursue a career in sports. Detailed history, elicited separately from the mother and the child, revealed frequent parental quarrels, and controlling and abusive behavior of the father. It was noted that DP harbored ambivalent feelings toward his father; though he feared him, he also had a strong desire for his love and acceptance. One of the significant thoughts that was eventually shared during the narratives was that the reason he spent hours practicing basketball was not triggered by personal motivation of becoming better, but rather an inexplicable feeling that somehow his excelling in sports would lead to decreased inter-parental hostility.

Family 3: MS, a 12-year-old boy, was referred for recurrent episodes of abnormal breathing for the past year, that was recognized as hyperventilation by the treating clinician. These episodes were brief, triggered off unexpectedly (according to his parents), occurred mainly at home in the evening, and were always in the presence of family members. The mother was concerned that the child had an underlying disease, that was being missed by the numerous doctors that they had consulted. According to her, the boy was academically bright, well-adjusted at school with several friends, and there were no complaints from the school teachers. Family history revealed that the mother had married a widower with two children from his previous marriage, who was the biological father of MS. The drawings made by MS [Figure 2] helped the team understand that there was possible alcohol abuse in the father. It emerged that there was frequent display of violent and abusive behavior after consumption of alcohol. MS would sometimes try to mediate the parental disputes by requesting his mother to leave the room or pleading with the parents to stop. This would inevitably lead to exacerbation of his symptoms. The child shared that he empathized with his mother and was determined to look after her financially and emotionally when he grew up.
Figure 2: Kinetic family drawing of MS displaying alcohol consumption by father. This was used as a springboard for further narrative therapy

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The compilation of additional clinical and background details of all the three cases are presented in [Table 1].
Table 1: Clinical profile, family background, and psychosocial stressors in each case

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Management and outcome

Comprehensive management plans were drawn for each case. It was decided that the primary treatment modalities would be art narratives that would enable the children to express their feelings in a psychologically safe environment. The drawings were used as a springboard for further discussion related to underlying family issues and interpersonal dynamics. Psychoeducation was provided to all family members and the connection between the functional symptoms and dysfunctional parental interactions in each family was underscored. In addition, the families were counseled regarding the importance of maintaining a congenial environment at home, and parents were advised to seek professional marital counseling. We provide a brief description of the individualized therapies used and their impact on the presenting complaints of each child.

Family 1: AS chose to write poetry to express his emotions and used his poems to alleviate his acute emotional distress at witnessing the endless conflicts and violent clashes of his parents. His poems touched on his dread of darkness and death. This was used as leverage for exploration and discussion of his feelings of sadness, helplessness, and anger. After three sessions spanning two months of therapy, AS reported that his physical symptoms had markedly declined. The healing was also reflected in his poetic writing wherein he wrote about the “joy of life” and “meeting his grave at hundred years” [Figure 3]. The latest follow-up done after a year of therapy revealed that AS has been asymptomatic, is attending school regularly, and excelling academically.
Figure 3: Poetry composed by AS before and after narrative therapy

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Family 2: DP on being asked to share his feelings through stories, narrated several tales about a boy lost in a treacherous forest infested by dangerous animals, and the struggles he had to endure to find safe passage out of those circumstances. His stories always ended with someone (a fairy or a saint), rescuing him from jaws of death at the last moment and leading him to safety. Gradually, the adolescent was also encouraged to interact more with his peers, spend time with nature, and practice deep breathing whenever he was exposed to IPV. After four months of therapy (covering three sessions), the symptoms of pain subsided. In the follow-up visit after 6 months, DP shared that he felt absolutely fine.

Family 3: The art and stories narrated by MS revolved about a boy and his current fears and struggles, as well as his aspirations of becoming a police officer who would control alcohol consumption among the public, as it was the genesis of all “evil actions.” MS was also encouraged to interact with his friends, and spend time playing and exercising outdoors, away from the family in the evenings. After three weekly sessions, the symptoms resolved and no recurrence was reported at a follow-up visit three months after initiation of therapy.


  Discussion Top


It is well established that dysfunctional parental relationships can lead to maladaptive coping and problems in parent–child attachment and negatively affect the child's psychological, behavioral, and physical well-being.[7],[8] “Child affected by parental relationship distress” is a newly introduced condition in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. This entails a description of how a clinician should assess the parent and child relationship and also probe into whether it affects the course, prognosis, and treatment of mental or other medical health disorders.

With respect to IPV, the greater the child's exposure to it, the worse are the potential psychological outcomes, unless timely interventions can help change the trajectory. Identifying the context in which the child's symptoms arise, in conjunction with identifying etiologically relevant psychosocial stressors, helps in formulating a comprehensive management plan. Research shows that traumatized children can paradoxically long for the love and acceptance of their abusive and neglectful parents, in addition to rejecting and fearing them.[8] Children exposed to IPV may experience difficulty in forming therapeutic relationships.

It has been observed that the recommended first-line interventions for functional somatic symptoms in adults, such as distraction and relaxation techniques, may not be as successful in children.[8],[9] A recent meta-analysis of 27 studies demonstrated that psychological modalities are the treatment of choice in children presenting with functional somatic symptoms.[10] Modalities like psychoeducation, relaxation, coping skills training, biofeedback, behavior therapy, and narrative therapies were found to reduce the severity of somatic symptoms and associated disability and improve school attendance.[10]

We presented this case series to highlight the fact that any early adversity including witnessing IPV can have a significant adverse impact on the physical and subjective wellbeing of children. Pediatricians should have a high index of suspicion of the possibility of psychosomatic conditions when their patients display inexplicable manifestations that do not fit into any recognizable clinical phenotype, either by description or after investigation. These children and adolescents should be referred for a psychological evaluation and further eclectic management. The use of creative narrative therapies in conjunction with other modalities can lead to successful resolution of functional somatic symptoms.



Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardians have given their consent for images and other clinical information to be reported in the journal. The guardians understand that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Kacker L, Varadan S, Kumar P. Study on Child Abuse: India 2007. New Delhi: Ministry of Women and Child Development, Government of India; 2007.  Back to cited text no. 1
    
2.
Krug EG, Dahlberg LL, Mercy JA, et al. World Report on Violence and Health. Geneva: World Health Organization; 2002.  Back to cited text no. 2
    
3.
Cater A, Miller L, Howell K, et al. Childhood exposure to intimate partner violence and adult mental health problems: Relationships with gender and age of exposure. J Fam Violence 2015;30:875-86.  Back to cited text no. 3
    
4.
Winding TN, Andersen JH. Do negative childhood conditions increase the risk of somatic symptoms in adolescence? – A prospective cohort study. BMC Public Health 2019;19:828.  Back to cited text no. 4
    
5.
Morison L, Simonds L, Stewart SF. Effectiveness of creative arts-based interventions for treating children and adolescents exposed to traumatic events: a systematic review of the quantitative evidence and meta-analysis. Arts Health 2021;1-26. doi:10.1080/17533015.2021.2009529 6.  Back to cited text no. 5
    
6.
Carroll R. Finding the words to say it: The healing power of poetry. Evid Based Complement Alternat Med 2005;2:161-72.  Back to cited text no. 6
    
7.
Bernet W, Wamboldt MZ, Narrow WE. Child affected by parental relationship distress. J Am Acad Child Adolesc Psychiatry 2016;55:571-9.  Back to cited text no. 7
    
8.
Westrupp EM, Brown S, Woolhouse H, et al. Repeated early-life exposure to inter-parental conflict increases risk of preadolescent mental health problems. Eur J Pediatr 2018;177:419-27.  Back to cited text no. 8
    
9.
Artz S, Jackson MA, Rossiter KR, et al. A comprehensive review of the literature on the impact of exposure to intimate partner violence for children and youth. Int J Child Youth Family Stud 2014;5:493-587.  Back to cited text no. 9
    
10.
Bonvanie IJ, Kallesøe KH, Janssens KA, et al. Psychological interventions for children with functional somatic symptoms: A systematic review and meta-analysis. J Pediatr 2017;187:272-81.e17.  Back to cited text no. 10
    


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