Article

The Family Journal: Counseling and

Therapy for Couples and Families
The Family System Amidst Complex Trauma: 2022, Vol. 30(4) 531-541
© The Author(s) 2022
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DOI: 10.1177/10664807221104115
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Aubrey D. Daniels1 , Julia Bryan2, Syrah Liles1, and JoLynn V. Carney2

Abstract
To explore the relationships between complex trauma, family cohesion, family environment, resiliency, and depression, the
authors employed hierarchical multiple regression and mediation analysis were employed with a sample of 485 young adults.
The sample consisted of three groups of participants based on the amount of trauma experienced, those who reported 1–3
trauma experiences, those who reported 3 or more trauma experiences, and those who did not report trauma. Analyses indi-
cated that despite complex trauma experiences, families were still able to cultivate strong family environment and family cohe-
sion, which enhanced resilience in individuals and in turn reduced depression symptoms. Future research, as well as important
implications for family counseling with the aim of enhancing family resilience and decreasing depression symptoms, especially as a
trauma response, are discussed.

Keywords
trauma, complex trauma, family environment, resilience, depression

Trauma is an experience which follows the intolerable
responses of heightened stress, emotional distress, and physical
pain (Arnold & Fisch, 2013). A person’s exposure to trauma
can impact their social, cognitive, spiritual, and emotional well-
ness. Specifically, we focused on complex trauma which is
chronic, ongoing traumas which have a higher likelihood to
impact child development (Arnold & Fisch, 2013; Vergano
et al., 2015). Complex trauma tends to occur within the
family system such as child abuse, child maltreatment, the wit-
nessing of intimate partner violence in the home, parental/care-
giver substance abuse, parental/caregiver mental health
struggles or suicidal ideation in the home, separation or
divorce of parents/caregivers, parentification, medical chal-
lenges, parent/caregiver incarceration, general absence of a
parent/caregiver, and community violence (Arnold & Fisch,
2013; Vergano et al., 2015). Foreman (2018) found counselors’
caseloads have a prevalence of trauma, while counselors are
also highly likely to experience vicarious traumatization.
Therefore, the topic of trauma is of high interest to family
counselors.
The chronic nature of complex trauma is correlated to
various physical and mental health issues. Physically,
complex trauma reactions trigger a release of cortisol in the
body which increases inflammation and has been correlated to
autoimmune disorders, issues with the endocrine system, lung
disease, heart disease, and liver disease (Lopes et al., 2020).
Typically, physical ailments are a stressor for individuals they
can worsen at unpredictable times. Furthermore, those who
are physically ill may feel isolated if they need to take time at
home to recover, or if they do not know others with similar ail-
ments as they have. Considering the emotional toll these phys-
ical ailments have on humans, they have been linked to mental
health challenges such as anxiety and depression (Ohrnberger
et al., 2017). Delving further into the mental health impacts
of complex trauma, those who experienced neglect or sexual
abuse during childhood were more likely to have a depressive
disorder and partake in violent acts of conduct as adolescents
(Lee et al., 2012). One sample of young adult women who
experienced complex trauma during childhood were found to
have correlated symptoms of depression in young adulthood
in comparison to those who did not experience complex
trauma (Chapman et al., 2004). These findings suggest the
need for more focus on symptoms of depression as a trauma
response in the counseling literature. Our study aims to better
address how depression symptoms may be impacted by resil-
ience and the family system.
1
Department of Graduate Education, Leadership, and Counseling, Rider
University, Lawrenceville, NJ, USA
2
Department of Educational Psychology, Counseling, and Special Education,
Penn State University, University Park, PA, USA
Corresponding Author:
Aubrey D. Daniels, Department of Graduate Education, Leadership, and
Counseling, Rider University, Bierenbaum-Fisher Hall 202, 2083 Lawrenceville
Rd, Lawrenceville, NJ 08648, USA.
Email: adaniels@rider.edu
532 The Family Journal: Counseling and Therapy for Couples and Families 30(4)
Despite significant findings focused on negative life out-
comes resulting from trauma, resilience is still possible
(Rosenberg et al., 2014). Resilience occurs when an individual
acclimates to their environment after adverse events (Ungar
et al., 2013). For example, acclimating post-event can consist
of a person recalling previous success they had during a
trying time, which enhances their confidence during future
adversity (Connor & Davidson, 2003). One aim of our study
was to understand the impact complex trauma during childhood
can have on young adults as it pertains to the depression, resil-
ience, and the family system.
Depression, Mental Health, and Complex
Trauma
Depression was one of the main variables assessed in our study.
Depression was defined as either a trauma response or a mental
health disorder in which people lose interest in previously
enjoyed activities, feel hopeless and helpless, experience
sadness, fatigue, may lack self-esteem, can appear indecisive or
have difficulty making decisions, feel chronically lonely, may
experience a change in sleep patterns, and may have bouts of sui-
cidal ideation (American Psychiatric Association, 2013).
Multiple studies have found that college students may experience
complex trauma at high rates which can lead to a negative impact
on a person’s mental health (Carey et al., 2018, Frazier et al.,
2009). For example, a sample of young adult women’s experi-
ences of complex trauma during childhood were correlated to
symptoms of depression in young adulthood in comparison to
those who did not experience complex trauma (Chapman et al.,
2004). Carey and colleagues (2018) also found that 28% of par-
ticipants reported at least one sexual abuse prior to college entry.
These participants reported elevated symptoms of anxiety and
depression frequently, with at least 1 in 8 students reported symp-
toms of depression that surpassed clinical thresholds (Carey
et al., 2018). These results present the case for the prevalence
of complex trauma prior to young adulthood. It is important to
understand complex trauma outcomes as repeated exposure to
trauma throughout an individual’s lifetime increases their risk
for experiencing symptoms of distress, including depression
(Frazier et al., 2009).
We aimed to understand if any relationship existed between
depression symptoms, resilience, family environment, and
family cohesion despite complex trauma during childhood.
Previous studies that did not account for protective factors
found complex trauma can increase risk for experiencing symp-
toms of distress, including depression (Frazier et al., 2009).
Considering individual’s risk for mental health concerns post
complex trauma, specifically depression (Frazier et al., 2009),
it was of particular interest to investigate which protective
factors bolster resilience in young adults, including family envi-
ronment and cohesion, and whether they mitigate the impact of
depressive symptoms after enduring complex trauma. The focus
on depression is imperative in the counseling literature consid-
ering it is highly prevalent in the United States (SAMHSA,
2014), and can be a trauma response (Vitriol et al., 2014). A
better understanding of the relationship between depression
and resilience can assist counselors with more effectively
decreasing depression symptoms in clients while enhancing
client resilience.
Resilience
Clients who display more resiliency, (e.g., holding hopeful atti-
tudes about the future, utilizing a support system, and having a
personal understanding of the meaning of life) learn how to
receive help via the surrounding resources to persevere during
or after traumatic events (Ungar et al., 2013). Such resources
consist of family support, neighbors, general community, and
schools (Ungar et al., 2013). Werner (1992) cultivated a list of
factors that build children and adolescents into resilient adults;
(1) adults encouraging children and adolescents to socially inter-
act with each other; (2) optimistic worldview, faith, responsibil-
ities, and goals; (3) Caregivers or Parents who model prosocial
behaviors; (4) Caregivers or Parents who enhance self-esteem
of children and adolescents; and, (5) Caregivers or Parents who
are resilient and trustworthy in the eyes of the child/adolescent.
Previous research has led to conclusions that people are
still able to demonstrate resiliency after trauma experiences
(McGloin & Widom, 2001; Masten & Wright, 2010).
Haverfield and Theiss (2016) found families who addressed
trauma experiences occurring in the family had higher resil-
ience levels and reduced depression symptoms in comparison
to families who avoided acknowledging trauma. The ability
to address trauma experienced within a family system could
be due to family cohesion, as the families may have the tools
to effectively communicate and higher comfort levels with
each other to address difficult topics. Robbins et al. (2018)
found that aspects of family environment, namely levels of
attachment-related maternal avoidance and paternal anxiety
negatively predicted resilience in their sample. This showed
how young adults may exhibit greater or lesser resilience in
the aftermath of enduring stressful life events dependent on
their level of attachment to their parent/caregiver during child-
hood. This secure attachment can lead to emotion regulation,
trust of others, and security in one’s family system, and positive
coping skills (Lindblad-Goldberg & Northey, 2013), all of
which are signs of resiliency. Family counselors recognize
that a portion of strengthening family resilience is enhancing
attachment in the family system (Walsh, 2016). Secure attach-
ments lead to comfort, trust, and commitment to the family
system. These families are better able to problem-solve, and
more easily access resources and coping skills to adapt to
their changed life experience as a result of the trauma or
crises, which is a sign of family resilience (Walsh, 2016).
Resilience, Depression, and the Family
System
The family resilience literature (Walsh, 2016) recognizes that
resilience is possible in children and adolescents who
Daniels et al.
experience complex trauma. Siriwardhana et al. (2014) found
the presence of familial support and other social supports
were found to decrease likelihood of severe depression in
young adults who experienced complex trauma during child-
hood. Findings such as these present the case for our study
focused on the relationship between family and resilience that
we hypothesized would decrease depression symptoms.
Resilience can also reduce depressive symptoms that an indi-
vidual experiences as a result of enduring complex trauma.
Individuals who are resilient are more likely to seek out
social support, community support, are flexible, and can regu-
late their emotions during adversity, so that a more resilient
individual who experiences depressive symptoms will be
better able to partake in self-care activities that can reduce
symptoms (Rosenberg et al., 2014).
When there is a lack of familial or parental support, children
may experience psychosis and other moderate to severe mental
health symptoms (Masten & Tellegen, 2012). We investigated
why the relationship between family, resilience, and depression
exists, which is the underlying reasoning that the family envi-
ronment and family cohesion variables were essential to
assess. In previous literature where mental health and resilience
are main constructs, they appear to be a related, but they lack
the variables to better describe why a relationship may exist.
This is seen in a sample of youth who endured complex
trauma, where a strong correlation existed between the
number of disorders youth were diagnosed with such as depres-
sion, PTSD and substance use, and the number of traumas expe-
rienced (Rosenberg et al., 2014). Rosenberg et al. (2014) found
a strong relationship between trauma and mental health diag-
noses, as youth who reported the average number of traumas
in the entire sample (N = 5.4) had seven times the likelihood
of screening for depression. Youth who experienced complex
trauma were at a greater risk for experiencing depressive
symptoms and ultimately a diagnosis of depression. Yet,
Rosenberg et al. (2014) did find resiliency is still possible in
young adulthood to mitigate the effects of complex trauma
on mental health symptoms. Considering these findings, we
assessed the specific levels of depression in comparison to
resilience levels. Our aim was to understand if resilience
was a mediator between the relationship of family environ-
ment and depression as well as family cohesion and depres-
sion, as we recognized a gap in the research to more fully
explain why resilience was possible.
Family Environment and Cohesion: The
Protective Factors to Decrease Depression
The family system can provide the supports that consist of
cohesion, religion, culture, values, independence, conflict,
organization, orientation, control and expressiveness (Moos &
Moos, 2009). Family cohesion is an important component
when considering the overall environment within a family
and is identified through empathy, connection, encouragement,
compassion, and caring for each other’s wellbeing (Moos &
533
Moos, 2009). When a positive force, family systems can lead
to resilience in children and adolescents leading to resilient
adults (McClure et al., 2008). Family cohesion has been
linked to resiliency where high levels of family cohesion are
associated with children’s self-confidence and self-efficacy in
the home which translates to school and community settings
(DiClemente et al., 2018). Family cohesion has been found to
enhance the quantity and quality of protective factors present
in a children and adolescent’s lives leading to more resiliency
as they age into young adults (McClure et al., 2008; Simpson,
2010).
Protective factors cultivated in the family system that may
lead to resiliency consist of collaboration with others,
belongingness, and self-restraint, which McClure et al.
(2008) found were still able to be cultivated in families
despite complex trauma exposure. Family cohesion is corre-
lated to enhanced bonds within a family, providing children
with the security of belonging in a group. Family cohesion
can also lead to children being adaptable, stronger communi-
cators, healthy boundary setters, and able to seek out healthy
relationships (Uruk et al., 2007). In households where such
cohesion exists, children and adolescents are comfortable
with expressing their feelings enhancing resiliency. Zhao
et al. (2015) found the presence of strong family cohesion
was correlated to lower depression in children. Family cohe-
sion was also correlated to some of the components of resil-
ience such as ability to adapt. Children who did not perceive
any family cohesion in their family system reported higher
levels of depression and more intense feelings of loneliness.
These findings further support the focus of the present study
to continue investigating the role family environment and
family cohesion have in resilience levels and depression
symptomatology.
Purpose of Study
Our first purpose for the present study was to assess the relation-
ships between the constructs, complex trauma, family environ-
ment, family cohesion, resilience, and depression. We assessed
whether the construct resilience impacts the depression in
young adults who experienced complex trauma. We also inves-
tigated if the relationship between family environment or family
cohesion and depression was mediated by resilience levels. Our
study was different than the majority of the complex trauma lit-
erature, as we measured a wide range of complex traumas rather
than honing in on a specific type of complex trauma. It is imper-
ative that the counseling research on complex trauma is;
(1) Focused on a wider range of complex trauma since all are
prevalent in client caseloads and; (2) more strengths focused
so family counselors have a better idea which client character-
istics should be highlighted to promote client resilience.
Considering correlations exist between complex trauma and
depression (Dworkin et al., 2017), we incorporated the variable
depression alongside the variables, family environment, family
cohesion, and resilience to understand if there are possible pos-
itive mental health outcomes.
534 The Family Journal: Counseling and Therapy for Couples and Families 30(4)
Research questions proposed in the present study were:
Research Question 1: Does family environment and resil-
iency predict depression after controlling for complex
trauma exposure?
Research Question 2: Does family cohesion and resil-
iency predict depression after controlling for complex
trauma exposure?
Research Question 3: Is resilience a mediator for the cor-
relation between family environment and depression?
Research Question 4: Is resilience a mediator for the cor-
relation between family cohesion and depression?
Method
Participants and Procedures
The sample consisted of 485 participants ages 18–35 (M = 25
years) with 84.7% of the sample female (n = 410) and 14.3%
male (n = 69). Participants also identified as non-binary (n = 3)
and agender (n = 2). Regarding race and ethnic identity, 78.4%
were White (n = 315), 8% were Asian (n = 32), 7.0% were
Hispanic/Latinx (n = 28), 4.2% were Black/African American
(n = 17), .5% were Native American (n = 2), and .2% were
Pacific Islander (n = 1). Of these demographics, 7.2% (n = 35)
participants identified with multiple race/ethnicities. Following
approval from our University’s Institutional Review Board
(IRB), young adults were recruited via various Facebook
groups, Twitter posts, Reddit feeds, email Listservs, and class-
room talks. A wide range of recruitment techniques was impor-
tant to obtain a diverse sample.
Instruments
Participants then completed the survey online via Qualtrics that
included a demographics questionnaire, ACE Questionnaire
(Felitti et al., 1998), Patient Health Questionnaire-9 (PHQ-9;
Spitzer et al., 1999), Connor-Davidson Resilience Scale
(CDRISC; Connor & Davidson, 2003), and Family Environment
Scale (FES; Moos & Moos, 2009).
Demographics Questionnaire. A 13-item questionnaire in place
to assess sociodemographic variables, knowledge of trauma,
quantity of family members, and changes in family over time.
Participants were able to select a response or insert their own
response as needed. Participants were also given the option to
skip questions.
Complex Trauma. The 10-item ACE Questionnaire (Felitti
et al., 1998) measured previous experiences of complex
trauma prior to the age of 18, and measured the quantity of
these experiences. Participants answered “yes”, “no”, or
“prefer not to answer” for each item. An example of an item
is, “Did you often feel that … No one in your family loved
you or thought you were important or special? or Your family
didn’t look out for each other, feel close to each other, or
support each other?” When participants respond, “yes” one
point is added to their final score. The questionnaire has a
high internal consistency (Cronbach alpha = .95), a strong
test-retest reliability, and strong construct validity (Poole,
et al., 2016). While coding the data, scores were re-coded
into three categories which consisted of (1) no trauma; a
score of 0; (2) low exposure; score 1–3 (3) high exposure; a
score of 4–10. The rationale for these categories was due to
the findings that complex trauma has stronger effects on those
whose score is 4 or higher. The no risk group was used as a ref-
erence group since they did not experience complex trauma.
Depression. The Patient Health Questionnaire 9 (PHQ-9;
Spitzer et al., 1999), a 10-item scale in Likert format assessed
symptoms and severity of depression over a period of two
weeks, following the DSM-5 (American Psychiatric
Association, 2013; Spitzer et al., 1999). There were five possi-
ble score outcomes for participants which consist of; severe
depression = 20–27, moderately severe depression = 15–19,
moderate depression = 10–14, mild depression = 5–9, and no
depression = 0–4. Overall, the PHQ-9 exhibited strong reliabil-
ity with a Cronbach alpha (.89). The PHQ-9 also has strong
construct validity and test-retest reliability (Kocalevent et al.,
2013), as well as high criterion validity (Lowe et al., 2004).
Resilience. The Connor-Davidson Resilience Scale (CD-RISC;
Connor & Davidson, 2003) a 25-item measure, assessed resil-
ience after complex trauma experiences. Resilience was mea-
sured by participant’s ability to cope with negative scenarios,
meaning of life, ability to take care of oneself, and humor in rea-
sonable circumstances (Connor & Davidson, 2003). Higher
scores are associated with high resilience levels. The
CDRISC (Connor & Davidson, 2003) has a high internal con-
sistency (Cronbach alpha = .89). When utilized with an adult
population who was considered high stress, the test-retest reli-
ability was .68 (Connor & Davidson, 2003; Wu et al., 2018).
Family Environment and Cohesion. The Family Environment
Scale (FES; Moos & Moos, 2009), a 90-item questionnaire,
which retroactively assessed family environment in the areas
of; communication within the family system, activities, reli-
gious experiences, disputes, and violence. Participants
answered each question with either “true”, “false”, and
“prefer not to say”. The various subscales consisted of cohe-
sion, conflict, expressiveness, achievement orientation, inde-
pendence, intellectual-cultural orientation, moral-religious
emphasis, active-recreational orientation, control, and organiza-
tion. When analyzing data, we focused on the entire FES as well
as the cohesion subscale. The test-retest reliability for the FES
was .68–.86, and internal consistency ranging .61–.78 (Lucey &
Lam, 2012; Moos & Moos, 1994). When used with a sample
who experienced alcoholism in a family system, there was
strong convergent validity (Sanford et al., 1999). Regarding
various cultures, when utilized with a sample of African
American and Latino youth the Cronbach alpha was slightly
Daniels et al.
less than .70 (Groenenberg et al., 2013). Meanwhile, when used
with a sample of Mexican American adults, Cronbach alpha
was .61–.78, with the cohesion subscale was stronger with a
Cronbach alpha of .78 (Negy & Snyder, 2006).
Internal Consistency of Instruments
Cronbach alphas were calculated as .89 for the PHQ-9 (Spitzer,
Kroenke & Williams, 1999); .74 for the ACE questionnaire;
and .92 for the CDRISC (Connor & Davidson, 2003). The
Cronbach alpha for the entire FES (Moos & Moos, 2009) was
.40 however, the family cohesion subscale Cronbach alpha
was .80. We assessed high internal consistency existed with
these instruments considering a Cronbach alpha of .70 or
more is appropriate (Taber, 2018).
Procedures
Inclusion criteria required young adults to be ages 18–35
(Jackson et al., 2012; Logan et al., 2016). Participants com-
pleted the survey online, which started with an overview of
the study, informed consent, as well as a trigger warning that
trauma questions would be asked. Participants were reminded
that their participation was voluntary and they were free to
quit their participation in the survey at any moment. Crisis
resources were listed following the trigger warning as well.
Once participants finished the survey, they were led to the
debriefing form.
Data Analysis
Participant data of individuals who were not ages 18–35 were
removed from the dataset for analysis. Other participant data
removed consisted of those who did not complete the survey,
only completed the demographic questionnaire, or did not com-
plete a significant portion of the survey to achieve scores for
each construct, which would skew the data when analyzed
(Graham, 2012). Histogram distributions and boxplots were
also utilized to assess if outliers were present. This investigation
led to one participant’s results being removed from the final
dataset, as this participant did not complete the family environ-
ment portion of the survey, meaning there was no score for that
section.
The demographic variables were evaluated via means, stan-
dard deviation, range, and frequencies. To understand the
strength and direction of correlations, Pearson coefficients
were employed (see Table 1). To assess the relationship
between (1) family environment, resilience, and depression
and (2) family cohesion, resilience, and depression with
complex trauma as the control variable in both models, hierar-
chical multiple regression was implemented. Prior to analyzing
the data via hierarchical multiple regression, various assump-
tions were checked such as; normality, linearity, independence,
homoscedasticity, and residual distribution (Tabachnick &
Fidell, 2007). We followed specific steps for hierarchical mul-
tiple regression analysis which were; (1) Complex trauma as
535
grouping variable (model 1); (2) model 2 consisted of the
addition of either family environment or family cohesion;
(3) Resilience was inputted into model 3; (4) The p value
(<.05), F, R2, Δ R2 were assessed during each step. Statistical sig-
nificance was considered numbers less than .05. The change in
R2 was also examined during each step in the model.
Results
Main variables intercorrelations are found on Table 1. The var-
iable correlations ranged from −.016 to .665. The correlations
did not exceed .70, therefore no threat to multicollinearity
existed (Tabachnick & Fidell, 2007). The means of the main
variables were: complex trauma 2.17 (SD = 2.3), family envi-
ronment (M = 49.8, SD = 10.2), family cohesion (M = 5.7, SD =
2.7), resilience (M = 7.4, SD = 16), and depression (M = 7.4,
SD = 5.7). The construct, complex trauma exposure was
created in three groups. Group one experienced a low exposure
of trauma, which was quantified as the experience of 1–3 types
of traumatic experiences (N = 219, M = 1.9). The next group
was a high exposure of complex trauma, which was the experi-
ence of 4–10 types of complex trauma (N = 113, M = 5.5). The
third group consisted of participants that did not experience
trauma (N = 147, M = 0).
Research Question 1
A hierarchical multiple regression with three models was uti-
lized to examine if family environment and resilience predicted
depression. Model one was focused on the complex trauma con-
struct with low trauma exposure and high trauma exposure
being inputted into model one. The reference group, no
trauma exposure was also inputted into the model. The variable,
complex trauma accounted for 16% of the variance in depres-
sion (R2 = .155, Δ R2 = .159, F (2,479) = 45.051, p < .000).
The variable, family environment was added to model two,
which accounted for.02% additional variance in depression
(R2 = .170, Δ R2 = .016, F (2,479) = 33.737, p < .001).
Resilience was added to model three, accounting for an extra
14% of variance in depression (R2 = .312, Δ R2 = .142,
F (2,479) = 55.306, p < .000). In model three, resilience
removed the statistical significance of family environment, sug-
gesting a direct relationship between family environment and
resilience (higher family environment score correlated to
higher resilience score). These findings suggest, family envi-
ronment may be correlated to high resilience levels which can
lead to low or no depression symptoms, defined as a score of
0–4 on the PHQ-9 (Spitzer et al., 1999).
Research Question 2
Another hierarchical multiple regression was employed to
examine if family cohesion and resiliency predict depression.
All three trauma groups were added to model one, with the par-
ticipants who experienced no trauma as the reference group. In
model one, 16% of the variance was accounted for by the
536 The Family Journal: Counseling and Therapy for Couples and Families 30(4)

Table 1. Intercorrelations for Main Variables.

Variable N 1 2 3 4 5 6 7

1. Resilience 480 -
2. Low Trauma Exposure 480 −.016 -
3. High Trauma Exposure 480 −.120* −.505* -
4. No Trauma 480 .127* −.604* −.367* -
5. Family Environment 480 .378* −.008* −.259* .253* -
6. Family Cohesion 480 .352* −.054 −.419* .454* 665* -
7. Depression 480 −.426* .087 .284* −.343* −.199* −.308* -

*p < .01.

variables (R2 = .155, Δ R2 = .159, F (2,479) = 45.051, p < Table 2. Hierarchical Multiple Regression: Relationship of Complex
.000). Family cohesion was added to model two, and accounted Trauma Exposure, Family Environment, and Resiliency to Depression
for an additional.03% of the variance for depression (R2 = .170, (N = 479).
Δ R2 = .025, F (2,479) = 35.794, p < .001). These results dem-
Step and
onstrate less trauma experiences may predict stronger family predictor
cohesion. When resilience was added to model three, it variable B SEB β R2 Δ R2 F
accounted for another 13% of the variance for depression (R2
= .312, Δ R2 = .133, F (2,479) = 55.247, p < .001) the addition Step 1 .155 .159*** 45.051
of resilience variable removed the significance of family cohe- High Trauma 6.127 .652 .458***
Exposure
sion. The results demonstrate, high family cohesion is corre-
Low Trauma 3.278 .556 .287***
lated to high resilience levels which are correlated to low or
Exposure
no depression. As expected, the findings were similar to those Step 2 .170 .016** 33.737
found for research question 1. High Trauma 5.498 .678 .411***
Exposure
Low Trauma 3.021 .557 .265***
Research Question 3 Exposure
In order to properly run a mediation model via hierarchical mul- Family −.077 .025 −.135**
tiple regression, four steps were followed to establish that a Environment
mediation existed prior to re-running the analyses in SPSS. Step 3 .312 .142*** 55.306
First, we assured all independent variables (complex trauma, High Trauma 5.283 .617 .395***
Exposure
family environment) had a statistically significant relationship
Low Trauma 2.828 .507 .248***
amongst each other as well as the dependent variable, depres-
Exposure
sion, this condition was met. The second step consisted of Family .020 .025 .034
assuring family environment (independent variable) had a stat- Environment
istically significant relationship with resilience, which was the Resiliency −.148 .015 −.415***
mediator. This condition was also met. Third, we investigated
if a statistically significant relationship existed between resil- ***p < .000, **p < .001, *p < .05.
Note. Reference group for Trauma Exposure was a score of 0.
ience (mediator) and depression (dependent variable), which
it did. Fourth, we were to analyze if the relationship between
the independent variable (family environment) and the depen- (β = .034, t(479) = .792, p = .429), suggesting resilience is a medi-
dent variable (depression) was either erased or reduced signifi- ator between family environment and depression (Table 2).
cantly. In this case, the relationship no longer existed
suggesting a mediation.
Once all conditions were met, we conducted the mediation anal-
ysis again via three steps using SPSS. In the first step of the medi- Research Question 4
ation model, a relationship existed between complex trauma and The same steps were repeated for question four however, a sub-
depression and was statistically significant (R2 = .155, Δ R2 = scale of family environment, family cohesion was inputted into
.159, F (2,479) = 45.051, p < .000). In step two, family environ- the model rather than the all-encompassing variable, family
ment was added to the model, and the relationship between environment. First, we assessed all independent variables
family environment and depression was statistically significant (complex trauma, family cohesion) has a statistically significant
(R2 = .170, Δ R2 = .016, F (2,479) = 33.737, p < .001). When the relationship amongst each other as well as the dependent vari-
mediator in step three, resilience was added and family environ- able, depression, this condition was met. The second step con-
ment lost statistical significance and no longer predicted depression sisted of assuring family cohesion (independent variable) had a
Daniels et al. 537

statistically significant relationship with resilience, which was trauma experiences. We also investigated how resilience
the mediator. This condition was met. Third, we investigated if might decrease depression. The results demonstrate that resil-
a statistically significant relationship existed between resilience ience is possible despite complex trauma exposures. Another
(mediator) and depression (dependent variable), which it did. main finding was that depression was lower in those with
Fourth, we were to analyze if the relationship between the indepen- higher resiliency. The variable resilience was found to be a
dent variable (family environment) and the dependent variable mediator between; (1) family environment and depression
(depression) was either erased or reduced significantly. In this and; (2) family cohesion and depression. Our results led to
case, the relationship no longer existed, suggesting mediation. more clarity regarding why people may display resilience and
Once all conditions were met, we conducted the mediation have less severe depression responses to trauma in comparison
analysis again via three steps in SPSS. In step one, a statistically to previous research (Dworkin et al., 2017). We found family
significant relationship existed between complex trauma and cohesion and family resilience were statistically significant in
depression (R2 = .155, Δ R2 = .159, F (2,479) = 45.051, p < enhancing resiliency in individuals despite previous trauma
.000). In step two, the regression relationship between family exposure.
cohesion and Depression was also statistically significant (R2 = Lee et al. (2018) hypothesized resilience may be a mediator
.170, Δ R2 = .025, F (2,479) = 35.794, p < .001), meaning between trauma and depression (Lee et al., 2018), but his study
family cohesion is a predictor of Depression (β = −.186, did not include a family variable. The current findings expand
t(479) = −3.833, p = .000). In step three, when the mediator, the possibilities that resilience is a mediator between family
resilience, was added to the model, it removed the statistically environment, cohesion and depression, thereby identifying
significant relationship between family cohesion and depression family assessment, support, and counseling as a means to
(β = −.069, t(479) = −.683, p = .495). This suggests, resilience enhance client resiliency and lower depression severity.
was a mediator for the relationship between family cohesion Considering depression can be a trauma response, a goal of
and depression (Table 3). ours was to analyze the variable depression to see how the
severity of depression changes in response to the other vari-
ables, including trauma exposure, family environment, family
Discussion cohesion, and resiliency. Dennison et al. (2016) found a statisti-
cally significant correlation between trauma exposure and
We aimed to advance the trauma research by focusing on depression (Dennison et al., 2016), which is aligned with the
factors that can enhance possibilities for resilience such as findings of the present study as complex trauma and depression
family environment and family cohesion despite complex were correlated prior to the addition of the other variables. Our
study adds to the mental health counseling literature, by demon-
Table 3. Hierarchical Multiple Regression: Relationship of strating that strong family environment or strong family cohe-
Complex Trauma Exposure, Family Cohesion, and Resiliency to sion may lead to resiliency that may decrease depression.
Depression (N = 479). These findings may be explained by the relationship between
loneliness and positive family environments, as the presence
Step and
of family is associated with lower levels of loneliness (Skopp
predictor
variable B SE B β R2 Δ R2 F et al., 2011). Meanwhile, higher levels of loneliness is associ-
ated with a lack of family support, and loneliness is one of
Step 1 .155 .159*** 45.051 the prominent depression symptoms (American Psychiatric
High Trauma 6.12 .652 .458*** Association, 2013).
Exposure Our findings demonstrate that despite complex trauma expe-
Low Trauma 3.278 .556 .287*** riences and depression symptomatology, families are still able
Exposure
to cultivate strong family environments and family cohesion
Step 2 .025 35.794
High Trauma 4.610 .755 .344***
and maintain resiliency. Masten & Reed (2002) also found
Exposure family as a force correlated with resiliency. Considering a
Low Trauma 2.577 .577 .226*** lack of family cohesion and environment is correlated to the
Exposure likelihood of an individual’s experience of severe depression
Family Cohesion −.398 .104 −.186*** in adolescence (Eisman et al., 2015), our findings can be inter-
Step 3 .312 .133 55.247 preted as insight into how counselors can utilize the family to
High Trauma 4.914 .692 .367*** decrease depression by using the family in counseling sessions
Exposure during childhood and adolescence in a trauma informed, resil-
Low Trauma 2.668 .529 .234*** ience focused manner.
Exposure
Family Cohesion −.069 .101 −.032
Resiliency −.140 .015 −.393*** Implications for Family Counselors
***p < .000, **p < .001, *p < .05. Considering our findings that family can positively impact out-
Note. Reference group for Trauma Exposure was a score of 0. comes pertaining to resiliency and depression, family
538 The Family Journal: Counseling and Therapy for Couples and Families 30(4)
counselors should utilize the family system in counseling ses-
sions. Strengthening the family system by increasing protective
factors helps to build resilience of individuals. The family resil-
ience method can be utilized to enhance the likelihood of indi-
vidual resiliency and other positive client outcomes. Family
counselors who build resilience in their clients are able to prior-
itize understanding the relationships, boundaries, culture, and
spirituality found in the family system as a means to understand
first, the strengths and next the areas for improvement or nega-
tive cycles of interaction in the family system (Walsh, 2016).
To build child-client resiliency, family counselors can learn
about the deficits in the family system and reframe or relabel the
ways in which family members label a particular situation, or
family member in the family system. For example, a family
that experiences complex trauma in the form of interpersonal
partner violence may label the identified client, typically a
child or adolescent as “bad” since the child does not
“comply” with the uncertain environment in their home.
Family counselors should note the negative labels placed on
identified clients and reframe by explaining to the family that
the child is responding to the intimate partner violence in the
home, and a behavioral response is expected in children
(Bremner, 2006; Mersky et al., 2013).
Family counselors can utilize the family resilience approach.
This approach is strengths-based, which is important for resilience
building and strengthening family systems (Walsh, 2016).
Treating depressive symptoms from a strengths-based approach
may improve young adults’ resiliency thus reducing the negative
pathological outcomes associated with complex trauma (Authors,
2021), and depression in particular. Counselors working with
young adults who endured trauma may choose to include the
family in sessions to lessen the risk of the client developing
depressive symptoms (Courtois, 2004).
Trauma and depression were two important variables in our
study especially as they relate to resilience. Interpersonal
Psychotherapy (IPT) (Ellis et al., 2018) is another approach
that counselors use to enhance resilience in clients who are
experiencing trauma and depression. Aspects of IPT may be
particularly useful since counselors can highlight the relation-
ships in an individuals’ lives and their roles across multiple
systems. For example, the family counselor may ask about
boundaries constructed in the family system and assess the
ways in which those boundaries (Teybur & McClure, 2011)
help or hinder a client as they move forward in other relation-
ships or systems such as their place of employment. This
portion of IPT can enhance client resilience as it pertains to
enhancing self-efficacy, more secure attachment, and greater
self-awareness.
IPT delves into shame as a response to previous trauma
exposure, and shame is also tied to depression symptomatology
(American Psychiatric Association, 2013). Following the IPT
approach, family counselors may ask clients about the ways
in which family members responded to their feelings of
sadness or some other feeling a client struggles to convey in
the counseling relationship. Further investigation of the
client’s response will lead to joining between the counselor
and client, and a space where the client can share their emotions
without shame, which builds resilience and can lead to healing
from depressive symptoms (Teybur & McClure, 2011). This
exercise can enhance family cohesion as they can gain a
better understanding of each other and strengthen communica-
tion moving forward. Furthermore, this use of an IPT approach
empowers clients to take control of how they conceptualize
their depression symptoms and take the next steps towards well-
ness (Kress et al., 2019).
Limitations
Our study contributed to the trauma and resilience literature in
the mental health counseling. However, multiple limitations are
still present. First, those who were willing to participate may be
more likely to have overcome previous trauma and felt comfort-
able enough to share their experiences as a result. There were
many attempts to diversify the sample regarding age range, eth-
nicity, education status, and socioeconomic status. Part of the
attempt consisted of participant recruitment outside of college
settings utilizing social media groups instead of solely recruit-
ing in college classrooms. Despite this attempt, 50% of the par-
ticipants were college students. A majority of the sample were
white and female as well. Furthermore, considering the study
was a self-report survey study, it can only be assumed that par-
ticipants were absolutely truthful in their responses. However,
stigma and shame could sway participant responses. Lastly,
causation cannot be deemed considering the study is correla-
tional. Some people do not perceive depression as an emotional
response, rather they are more in tune with the physical symp-
toms of depression (Dailey et al., 2014), participants who quan-
tify depression more physically may not be accounted for in the
data.
Future Research
A larger variety of constructs that may promote resilience after
trauma exposure should be assessed, in future studies. Further
investigation of family variables and family relationships may
enhance the literature considering that we found statistically
significant relationships between family environment, cohe-
sion, depression, and resilience. Research focused on the coun-
seling process of families who experienced trauma is needed to
understand how to better prevent negative impacts of trauma.
Such studies will assist counselors in the pursuit of providing
higher quality care for children, adolescents, and families.
Additional research on other counseling approaches for depres-
sion as a trauma response such as IPT would be beneficial, espe-
cially considering IPT tends to only be taught in advanced
graduate courses or solely at the doctoral level depending on
the program.
Conclusion
A gap that exists in the counseling literature is the lack of
strengths-based research with resiliency outcomes as it pertains
Daniels et al.
to trauma experiences. Our findings provide a better under-
standing of positive outcomes in clients who experience
trauma. Meaning, clients can experience trauma and also
display resilience. Furthermore, higher levels of resilience
levels can decrease depression symptomatology. Therefore,
we suggest family counselors place a high importance on the
family system. Despite the chaotic experience of trauma,
there is still hope for a positive family environment and cohe-
sion. Thus, family counselors should aim to fortify family
systems when working with families impacted by trauma.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship,
and/or publication of this article.
ORCID iD
Aubrey D. Daniels https://orcid.org/0000-0003-1373-9755
References
American Psychiatric Association (2013). Diagnostic and statistical
manual of mental disorders, 5. American Psychiatric Publishing.
Arnold, C., & Fisch, R. (2013). The impact of complex trauma on
development. Jason Aronson Inc.
Authors (2021). Resilience despite complex trauma: Family environment
and family cohesion as protective factors. The Family Journal, 29(3),
336–345. https://doi.org/10.1177/10664807211000719
Bremner, J. D. (2006). Traumatic stress: Effects on the brain.
Dialogues in Clinical Neuroscience, 8(4), 445–461. https://doi.
org/10.31887/DCNS.2006.8.4/jbremner
Carey, K. B., Norris, A. L., Durney, S. E., Shepardson, R. L., & Carey,
M. P. (2018). Mental health consequences of sexual assault among
first-year college women. Journal of American College Health,
66(6), 480–486. https://doi.org/10.1080/07448481.2018.1431915.
Chapman, D. P., Whitfield, C. L., Felitti, V. J., Dube, S. R., Edwards, V. J.,
& Anda, R. F. (2004). Adverse childhood experiences and the risk of
depressive disorders in adulthood. Journal of Affective Disorders,
82(2), 217–225. https://doi.org/10.1016/j.jad.2003.12.013.
Connor, K. M., & Davidson, J. R. T. (2003). Development of a new resil-
ience scale: The Connor-Davidson Resilience Scale (CD-RISC).
Depression and Anxiety, 18(2), 76–82. https://doi.org/10.1002/da.10113.
Courtois, C. A. (2004). Complex trauma, complex reactions:
Assessment and treatment. Psychotherapy (Chicago, Ill.), 41(4),
412–425. https://doi.org/10.1037/1942-9681.S.1.86.
Dailey, S. F., Gill, C. S., Karl, S. L., & Minton, C. A. B. (2014). DSM-5
learning companion for counselors. American Counseling Association.
Dennison, M. J., Sheridan, M. A., Busso, D. S., Jenness, J. L., Peverill,
M., Rosen, M. L., & McLaughlin, K. A. (2016). Neurobehavioral
markers of resilience to depression amongst adolescents exposed
to child abuse. Journal of Abnormal Psychology, 125(8), 1201–
1212. https://doi.org/10.1037/abn0000215.
539
DiClemente, C. M., Rice, C. M., Quimby, D., Richards, M. H., Grimes,
C. T., Morency, M. M., White, C. D., Miller, K. M., & Pica, J. A.
(2018). Resilience in urban African American adolescents: The protec-
tive enhancing effects of neighborhood, family, and school cohesion
following violence exposure. The Journal of Early Adolescence,
38(9), 1286–1321. https://doi.org/10.1177/0272431616675974.
Dworkin, E. R., Menon, S. V., Bystrynski, J., & Allen, N. E. (2017).
Sexual assault victimization and psychopathology: A review and
meta-analysis. Clinical Psychology Review, 56, 65–81. https://doi-
org./10.1016/j.cpr.2017.06.002.
Eisman, A. B., Stoddard, S. A., Heinze, J., Caldwell, C. H., &
Zimmerman, M. A. (2015). Depressive symptoms, social support,
and violence exposure among urban youth: A longitudinal study
of resilience. Developmental Psychology, 51(9), 1307–1316.
https://doi.org/10.1037/a0039501
Ellis, A. E., Simiola, V., Brown, L., Courtois, C., & Cook, J. M.
(2018). The role of evidence-based therapy relationships on treat-
ment outcome for adults with trauma: A systematic review.
Journal of Trauma & Dissociation, 19(2), 185–213. https://doi.
org/10.1080/15299732.2017.1329771.
Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A.
M., Edwards, V., & Marks, J. S. (1998). Relationship of childhood
abuse and household dysfunction to many of the leading causes of
death in adults: The adverse childhood experiences (ACE) study.
American Journal of Preventive Medicine, 14(4), 245–258.
https://doi.org/10.1016/S0749-3797(98)00017-8
Foreman, T. (2018). Wellness, exposure to trauma, and vicarious trau-
matization: A pilot study. Journal of Mental Health Counseling,
40(2), 142–155. https://doi.org/10.17744/mehc.40.2.04
Frazier, P., Anders, S., Perera, S., Tomich, P., Tennen, H., Park, C., &
Tashiro, T. (2009). Traumatic events among undergraduate stu-
dents. Journal of Counseling Psychology, 56(3), 450–460. https://
doi.org/10.1037/a0016412.
Graham, J. W. (2012). Missing data: Analysis and design.
Springer.
Groenenberg, I., Sharma, S., Green, B. S., & Fleming, S. E. (2013).
Family environment in inner-city African-American and Latino
parents/caregivers: A comparison of the reliability of instruments.
Journal of Child and Family Studies, 22(2), 288–296. https://doi.
org/10.1007/s10826-012-9578-0
Haverfield, M. C., & Theiss, J. A. (2016). Parent’s alcoholism severity
and family topic avoidance about alcohol as predictors of perceived
stigma among adult children of alcoholics: Implications for emo-
tional and psychological resilience. Health Communication,
31(5), 606–616. https://doi.org/10.1080/10410236.2014.981665.
Jackson, P. A., Deary, M. E., Reay, J. L., Scholey, A. B., & Kennedy, D. O.
(2012). No effect of 12 weeks’ supplementation with 1g DHA-rich or
EPA-rich fish oil on cognitive function or mood in healthy young
adults aged 18–35 years. British Journal of Nutrition, 107(8), 1–12.
https://doi.org/10.1017/S000711451100403X
Kocalevent, R. D., Hinz, A., & Brähler, E. (2013). Standardization of
the depression screener patient health questionnaire (PHQ-9) in the
general population. General Hospital Psychiatry, 35(5), 551–555.
https://doi.org/10.1016/j.genhosppsych.2013.04.006
Kress, V. E., Paylo, M. J., & Stargell, N. A. (2019). Counseling chil-
dren and adolescents. Pearson.
540 The Family Journal: Counseling and Therapy for Couples and Families 30(4)
Lee, C., Cronley, C., White, H. R., Mun, E., Stouthamer-Loeber, M., &
Loeber, R. (2012). Racial differences in the consequences of child-
hood maltreatment for adolescent and young adult depression,
heavy drinking, and violence. Journal of Adolescent Health,
50(5), 443–449.
Lee, S. W., Bae, G. Y., Rim, H., Lee, S. J., Chang, S. M., Kim, B., &
Won, S. (2018). Mediating effect of resilience on the association
between emotional neglect and depressive symptoms.
Psychiatry Investigation, 15(1), 62–69. https://doi.org/10.
4306/pi.2018.15.1.62
Lindblad-Goldberg, M., & Northey, W. F., Jr. (2013). Ecosystemic
structural family therapy: Theoretical and clinical foundations.
Contemporary Family Therapy, 35(1), 147–160.
Logan, J. E., Fowler, K. A., Patel, N. P., & Holland, K. M. (2016).
Suicide among military personnel and veterans aged 18–35 years
by county—16 states. American Journal of Preventive Medicine,
51(5), S197–S208. https://doi.org/10.1016/j.amepre.2016.06.001
Lopes, S., Hallak, J. E. C., Machado de Sousa, J. P., & Osório, F. d. L.
(2020). Adverse childhood experiences and chronic lung diseases
in adulthood: A systematic review and meta-analysis. European
Journal of Psychotraumatology, 11(1), 1–11. https://doi.org/10.
1080/20008198.2020.1720336.
Löwe, B., Kroenke, K., Herzog, W., & Gräfe, K. (2004). Measuring
depression outcome with a brief self-report instrument:
Sensitivity to change of the patient health questionnaire (PHQ-9).
Journal of Affective Disorders, 81(1), 61–66. https://doi.org/10.
1016/S0165-0327(03)00198-8
Lucey, C. F., & Lam, S. K. Y. (2012). Predicting suicide risks among
outpatient adolescents using the family environment scale:
Implications for practice and research. International Journal for
the Advancement of Counselling, 34(2), 107–117. https://doi.org/
10.1007/s10447-011-9140-6
Masten, A. S., & Reed, M.-G. J. (2002). Resilience in development. In
C. R. Snyder, & S. J. Lopez (Eds.), Handbook of positive psychol-
ogy (pp. 74–88). Oxford University Press.
Masten, A. S., & Tellegen, A. (2012). Resilience in developmental
psychopathology: Contributions of the project competence longitu-
dinal study. Development and Psychopathology, 24(2), 345–361.
https://doi.org/10.1017/S095457941200003X
Masten, A. S., & Wright, M. O. (2010). Resilience over the lifespan:
Developmental perspectives on resistance, recovery, and transfor-
mation. In J. W. Reich, A. J. Zautra, & J. S. Hall (Eds.),
Handbook of adult resilience (pp. 213–237). The Guilford Press.
McClure, F. H., Chavez, D. V., Agars, M. D., Peacock, M. J., &
Matosian, A. (2008). Resilience in sexually abused women: Risk
and protective factors. Journal of Family Violence, 23(2), 81–88.
https://doi.org/10.1007/s10896-007-9129-4
Mcgloin, J. M., & Widom, C. S. (2001). Resilience among abused
and neglected children grown up. Development and
Psychopathology, 13(4), 1021–1038. https://doi.org/10.1017/
S095457940100414X
Mersky, J. P., Topitzes, J., & Reynolds, A. J. (2013). Impacts of
adverse childhood experiences on health, mental health, and sub-
stance use in early adulthood: A cohort study of an urban, minority
sample in the U.S. Child Abuse & Neglect, 37(11), 917–925. https://
doi.org/10.1016/j.chiabu.2013.07.011
Moos, R. H., & Moos, B. S. (1994). Family environment scale manual
(3rd ed.). Consulting Psychologists Press.
Moos, R., & Moos, B. (2009). Family environment scale manual and
sampler set: Development, applications and research (4th ed.).
Mind Garden, Inc.
Negy, C., & Snyder, D. K. (2006). Assessing family-of-origin func-
tioning in Mexican American adults: Retrospective application
of the family environment scale. Assessment, 13(4), 396–405.
https://doi.org/10.1177/1073191106289809
Ohrnberger, J., Fichera, E., & Sutton, M. (2017). The relationship
between physical and mental health: A mediation analysis. Social
Science & Medicine (1982), 195, 42–49. https://10.1016/j.
socscimed.2017.11.008.
Poole, J. C., Dobson, K. S., & Pusch, D. (2016). Childhood adversity
and adult depression: The protective role of psychological resil-
ience. Child Abuse & Neglect, 64, 89–100. https://doi.org/10.
1016/j.chiabu.2016.12.012
Robbins, A., Kaye, E., & Catling, J. C. (2018). Predictors of student
resilience in higher education. Psychology Teaching Review,
24(1), 44–52.
Rosenberg, H. J., Vance, J. E., Rosenberg, S. D., Wolford, G. L.,
Ashley, S. W., & Howard, M. L. (2014). Trauma exposure, psychi-
atric disorders, and resiliency in juvenile-justice-involved youth.
Psychological Trauma: Theory, Research, Practice, and Policy,
6(4), 430–437. https://doi.org/10.1037/a0033199.
Sanford, K., Bingham, C. R., & Zucker, R. A. (1999). Validity issues
with the family environment scale: Psychometric resolution and
research application with alcoholic families. Psychological
Assessment, 11(3), 315–325. https://doi.org/10.1037/1040-3590.
11.3.315
Simpson, C. L. (2010). Resilience in women sexually abused as chil-
dren. Families in Society: The Journal of Contemporary Social
Services, 91(3), 241–247. https://doi.org/10.1606/1044-3894.4001
Siriwardhana, C., Ali, S. S., Roberts, B., & Stewart, R. (2014). A sys-
tematic review of resilience and mental health outcomes of conflict-
driven adult forced migrants. Conflict and Health, 8(1), 13. https://
doi.org/10.1186/1752-1505-8-13
Skopp, N. A., Luxton, D. D., Bush, N., & Sirotin, A. (2011).
Childhood adversity and suicidal ideation in a clinical military
sample: Military unit cohesion and intimate relationships as protec-
tive factors. Journal of Social and Clinical Psychology, 30(4),
361–377. https://doi.org/10.1521/jscp.2011.30.4.361
Spitzer, R. L., Kroenke, K., & Williams, J. B. W., & The Patient Health
Questionnaire Primary Care Study Group. (1999). Validation and
utility of a self-report version of PRIME-MD: The PHQ primary
care study. Jama, 282(18), 1737–1744. https://doi.org/10.1001/
jama.282.18.1737
Substance Abuse and Mental Health Services Administration. (2014).
Understanding Childhood Trauma. Substance Abuse and Mental
Health Services Administration.
Tabachnick, L. S., & Fidell, B. G. (2007). Using multivariate statistics
(6th ed.). Pearson.
Taber, K. S. (2018). The use of cronbach’s alpha when developing and
reporting research instruments in science education. Research in
Science Education, 48(6), 1273. https://doi.org/10.1007/s11165-
016-9602-2
Daniels et al.
Teybur, E., & McClure, F. H. (2011). Interpersonal process theory: An
integrative model. Cengage.
Ungar, M., Ghazinour, M., & Richter, J. (2013). Annual research
review: What is resilience within the social ecology of human
development? Journal of Child Psychology and Psychiatry,
54(4), 348–366. https://doi.org/10.1111/jcpp.12025
Uruk, AÇ, Sayger, T. V., & Cogdal, P. A. (2007). Examining the influence
of family cohesion and adaptability on trauma symptoms and psycho-
logical well-being. Journal of College Student Psychotherapy, 22(2),
51–63. https://doi.org/10.1300/J035v22n02_05
Vergano, C. M., Speranza, A. M., & Lauriola, M. (2015). The complex
trauma questionnaire (ComplexTQ): Development and preliminary
psychometric properties of an instrument for measuring early rela-
tional trauma. Frontiers in Psychology, 6, 13–23. https://doi.org/10.
3389/fpsyg.2015.01323
Vitriol, V., Cancino, A., Weil, K., Salgado, C., Asenjo, M. A., &
Potthoff, S. (2014). Depression and psychological trauma: An
541
overview integrating current research and specific evidence of
studies in the treatment of depression in public mental health ser-
vices in Chile. Depression Research and Treatment, 2014, 1–10.
https://doi.org/10.1155/2014/608671.
Walsh, F. (2016). Strengthening family resilience (3rd ed.). The
Guilford Press.
Werner, E. E. (1992). The children of Kauai: Resiliency and recovery
in adolescence and adulthood. Journal of Adolescent Health, 13(4),
262–268. https://doi.org/10.1016/1054-139X(92)90157-7
Wu, L., Tan, Y., & Liu, Y. (2018). Factor structure and psychometric
evaluation of the Connor-Davidson resilience scale in a new
employee population of China. BMC Psychiatry, 17(1), 49.
https://doi.org/10.1186/s12888-017-1219-0
Zhao, J., Liu, X., & Wang, M. (2015). Parent–child cohesion, friend
companionship and left-behind children’s emotional adaptation in
rural China. Child Abuse & Neglect, 48, 190–199. https://doi.org/
10.1016/j.chiabu.2015.07.005