1. Rossie Young People’s Trust: Trauma Informed Lens
Dr Ian Barron
University of Dundee

2. Content What is a traumatic event?
Impact of traumatic events (PTSD, DTD, dissociation & traumatic grief)
Size of the problem
Myths, Risks & Protective Factors
Neurobiology of T, Traumatic Memory & Triggers
Trauma-informed assessment
Trauma-informed & trauma-specific interventions (TRT)
Vicarious trauma & staff care

3. Types of experience that may be traumatic for YP and parents/carers
Accidents
Disasters
Terrorism
War
Torture
Abuse
Murder
Domestic violence
Bullying
Gang violence
Other??

4. Trauma typologies (acute and chronic)
Simple traumas – often single events, over and in the past, e.g. RTA’s, specific phobias, assault, bereavement
Complex traumas – usually multiple experiences and not just in the past, e.g. molested by father who remains in the home, complicated grief from murder of parents
(Tinker and Wilson, 1999)

5. T Events for Rossie YP
What traumatic events are you aware of in YP in Rossie Accommodation Service?

6. T events (Rossie files) – multiples!
Physical abuse
Sexual abuse
Witness DV
Witness physical abuse
Hospital
Neglect
Emotional/impaired care giver - Parents drug taking
Loss – into care from home; parent separated, into prison
Multiple placements & into Rossie
Legal - Hearings/case conferences/reviews

7. 92.5% at least one T type YP 50% six or more T types
Secure accommodation
92.5% at least one T type YP
50% six or more T types
(Abram et al., 2004) 7

8. Impact of T event? Definition-
“An event that threatens the life of self and people close to you, or threatens the integrity of the body, and overwhelms coping resources…”
PTSD has three axes:
Re-experiencing including flashbacks, intrusive thoughts, nightmares
Avoidance including, phobias, numbing, dissociation, use of drugs & alcohol
Hyper-arousal including hyper-vigilance, exaggerated startle response, sleep disorders, anxiety.
TRAUMATIC EVENT which is most likely to lead to PTSD is rape, more so than armed conflict and torture.

9. PTSD
What signs do you see in Rossie young people of PTSD?

10. Examples PTSD: Rossie YP files
Intrusion
Recurring worry/thoughts
Avoidance
Alcohol & substance misuse; absconding (Hearings; Reviews as triggers); dissociative states (unreasonable, irrational, emotionally cold, unresponsive; memory difficulties; avoiding unpleasant thoughts
Arousal
Quick temper; low tolerance of frustration; impulsive; agitated, upset; restless, fidgety, inattentive; violent, excessive anger (out of proportion); reactive lashes out (feels unsafe uncontained)

11. PTSD in Children
DSM IV criteria for even simple, single event trauma, is unsatisfactory for children (Atle Dyregrov)
Adult oriented criteria difficult for children to fulfil - leads to under- estimation PTSD in children.
Criteria highly unsuitable for children who have suffered multiple abuse at an early age, usually by their caregivers (van der kolk)
Proposes new diagnosis, developmental trauma disorder, parallels complex PTSD in adults (early childhood abuse)
Developing brain more susceptible to damage and neuro-chemical imbalances than the mature brain (Schwarz and Perry 1994)
Developmental Trauma Disorder should replace the multiple diagnoses these children often get from different health professionals, e.g. ADD, OCD, Autism, Tourettes, ADHD.
Trauma obscured and minimised – lack of connections between disorders and antecedent emotional events.

12. Developmental Trauma Disorder
Takes account of repeated violation of young children, often by the caregiver, effects at ages and stages.
Foreshortened and diminished view of future
The world has become a bad place
Inability to trust
Attributing hostile intentions to neutral stimuli
Problems with sex and sexuality
Maladaptive coping mechanisms - harming self through substance abuse, eating disorders, cutting, suicide
Re-victimized in adult life, living in violent relationship
Blocked empathy, hardening of heart
Harming others, re-enacting but putting other in victim role, sadistic personality

13. DTD in Rossie
What signs of Developmental Trauma Disorder do you see in the Rossie YP populations?

14. DTD in Rossie YP Files
Substance misuse; Prostitution; sexual re-victimisation; gang violence; physical assaults to YP & adults
Torture; self harm, attempted suicides; phobias & social anxieties, not care about for self/others; not feel for others; fire-raising; harm animals
Verbally abusive; emotionally volatile; absconding, little hope or idea for a different future

15. Dissociation Recurrent blank spells, periods of missing time
Auditory hallucinations (in head)
Severe chronic childhood trauma (flashbacks)
Shifts in ego state or personalities
Also -
Headaches
Physical complaints
Depersonalisation – (Detached feeling of watching oneself act)
De-realisation – (Disconnection, dream like state)
Dissociative Amnesia (Cannot recall traumatic periods, events or people)
Sleep disturbance/night terrors

16. Traumatic Grief
Delayed or absent grief - grief that is not expressed often accompanied by a preoccupation with the welfare of others.
Chronic grief - grief that continues or is excessive Responses are intense and protracted, often limited in range of emotions
Inhibited or distorted grief - inhibited and excessive grief is at some level a failure to acknowledge and accept death
Traumatic block - to grief expression (e.g. rage)

17. Blocks to processing grief
Self-reproach, guilt, survivor guilt
Idealization
Striving for or losing control,
Loss or destabilization of parenting, over- protectiveness, loss or disruption of location and routines

18. Signs of traumatic grief
Mood changes - sad, aggressive, anxious
Preoccupation
Loss of self-esteem
Bedwetting, sleep disturbance, nightmares,
Separation difficulties
Somaticisation (physical symptoms of more than one part of the body without physical cause)
Peer difficulties
Loss of school performance etc.

19. Traumatising & traumatised Parents
Impact of PTSD, dissociation & drug misuse on attachment; shame, guilt
Knock on losses; legal issues
Messages of non-safety & danger
Social engagement problems – modeling poor affect regulation
Interpret YP needs - self referential
Enmeshed; attunement impaired (reactiveness to babies needs and emotions)
Intergenerational trauma
Parent response significant for child’s recovery

20. Extent of the PTSD in Community
By 18 years 40% of youths community sample met criteria for at least one trauma and 6% met criteria for lifetime diagnosis of PTSD.
50% sexual assault suffer PTSD in longer term (Green, 1994)
Underestimate 10-20% children PTSD
The commonest cause in girls in sexual assault and in boys involvement in or witness to acts of violence.

21. Extent of PTSD in Secure Accommodation
67-90% PTSD in secure (Drerup et al, 2008)
10 to 15 times more PTSD than general population (Copeland et al., 2007)
Early & multiple Ts leads to greater symptom complexity and co-morbidity - meet criteria for range of other MH disorders
Anger, anxiety, guilt, persistent –ve emotions (Abram et al., 2007) – DSM5 PTSD
Violence and victimisation pervasive in YP lives – associated with MH & substance misuse

22. Myths Too young to be aware or appreciate what is going on around them
Effect short lived
Resilient - naturally recover by forgetting, getting over it or growing out of it
Lack of obvious symptoms means the event has not negatively impacted on the child

23. RISK FACTORS The event itself high degree of exposure
unexpectedness, duration and number of episodes
threat to own life
injury, pain and violation to the integrity of the body
trapped without assistance/hearing cries for help
strong sensory impressions
relationship of the assailant/other victims
The individual
developmental stage
sensitive personality
intelligence
coping as learned behaviour
pre-existing problems
previous traumatic experiences

24. PROTECTIVE FACTORS Strong attachments
Coping modelled as learned behaviour
Recovery environment including safety, secure base and continuity
Opportunities to reconnect to resources (efficacy, competence)
Opportunity to regress
Time with peers, carers & community support
Support to see the wider picture (integration of experiences)
Parry Jones (1995)

25. Neurobiology: Why is traumatic memory different from normal autobiographical memory?
Normal, autobiographical memory fades over time.
It is a memory of an event, that something happened. It is continually reconstructed as our understanding and mood changes.
Traumatic Memories are laid down under severe threat and extreme emotion
They can be triggered again by a feature or event similar to the original trauma, even before they are consciously aware of any threat
They can also be triggered by talking about the T event.
They are re-experienced in the same vividness, together with the same body sensations and horror, terror and helplessness as the original event. It is as if it’s all happening again.

26. TM versus autobiographical memory: “The body keeps the score”
Memory is ‘burnt in’ and gets burnt in even deeper if the
TM is activated - re-traumatizes.
Doesn’t deteriorate/decay over time, sense of it always
being in the current present
All present and future events are seen through this
trauma lens of terror and helplessness
Timeless and immutable
High level of accuracy, more detail as child gets older
and has more mature concepts to describe the internal
and external world.
Why should TM be so different?

27. A. The Structure of the Brain The Triune Brain - Paul MacLean 1985
1. Reptilian brain (body regulation, sensori- motor)
2. Mammalian brain, (emotion) limbic system plus reptilian brain
3. Neocortex, (cognitive) plus the limbic system, plus the reptilian brain
= Three levels of
processing
Karen
MODEL OF BRAIN BASED ON ITS
EVOLUTIONARY DEVELOPMENT

28. The Triune Brain – one mind three Brains
Evolutionary development – the triune brain (McLean, 1967)
Top down and bottom up processing
Brainstem – “reptilian brain”, instinctive responses, language of body sensation and impulse
Limbic system – “mammalian brain”, somato-sensory and emotional experience and implicit memory (non-verbal), language of emotion and feeling tones
Frontal cortex – “homosapians brain”, intellectual and executive functioning, verbal language, conscious thought and self awareness, language of thought and verbal expression (Ogden 2006)
2 to 3 months limbic brain begins to develop, aged 13 years growth spurt frontal cortex (teenagers disappointed parents not perfect), aged 22 final maturation (parents did as good as they could)
As children get older they have more ability to use frontal cortex to manage emotion (Fisher, 2003)

29. Neurobiology of Traumatic Memory
When the brain detects a threat, through incoming sensory information, the part of the emotional brain - the amygdala, acts as a smoke alarm, deals with the fear response, becomes highly aroused. This gets ready to activate the fight and flight system, through the hypothalamus (above brain stem – temperature, thirst, fatigue, anger).
If the cortex evaluates the situation as no threat, the adrenalin response gets gated, and the system calms down.
If it evaluates the threat as serious, then the fight and flight system will ‘go off’ (one synapse compared to seven – Le doux)
However, if the threat is sudden and very serious, the fight and flight can go off before the information has reached consciousness. Neurochemical release, inc heart rate and respiration, rush of energy to muscle tissue, inhibition of frontal lobes, suppression of non- essential systems (eat, drink and urinate), e.g. mother lifts car off baby!
This can be very adaptive and life saving (bus!)

30. Neurobiology
However, if the person’s coping mechanisms are overwhelmed, and there is a freeze rather than fight and flight response, the person becomes helpless and a traumatic memory forms.
The incoming somato-sensory information, complete with the feelings of horror, helplessness and terror are stored as fragments in the amygdala and brain stem.
They are not recycled through the hippocampus (emotion and memory) into the anterior cingulate cortex (blood pressure and rational thought) to form a sketch of the episode. The continued recycling necessary to get rid of the perceptual, emotional and body sensations does not occur. The memory remains embodied and unprocessed, and unavailable to reflection and consideration.
The memory is dissociated from normal autobiographic memory. There is no coherent narrative. Raw data remains encoded in the amgdala like a sensory photograph of the event.
Brains smoke alarm get increasingly sensitised to even subtle reminders and sets off false alarms, e.g. shadow could mean predator.

31. Traumatic Reminders
If something in the environment is perceived as similar to the original trauma, the amygdala will set off the fight and flight or freeze mechanisms, again before the cortex can evaluate the threat.
The cortex has been hijacked by the amygdala.
The somato-sensory elements in the amygdala become activated as flashbacks.
The event is thus re-experienced, together with the original feelings of terror, horror, helplessness
The cortex shuts down - what is not needed is closed down.
“Don’t think or you will hesitate, or get confused, you will die.” Isabel Allende
The cortex and limbic system may shut down so that that they lose awareness of the surroundings, speech and feeling – looking glassy and mute. They are dissociated.

32. ctd
So, under extreme threat we revert to our more primitive behaviours which are part of our reptilian heritage, when the R-complex takes over the survival responses.
Pierre Janet, Van der Kolk, Peter Levine, Pat Ogden and others, think that defences get disabled, and helplessness and the freeze response occurs (e.g. battered women), the uncompleted act of survival is embodied. And this is the PTSD.
What is needed in therapy is a return to the event, and reactivation of the defences to complete the ‘act of triumph’
Even talking about the traumatic event can activate the traumatic memory, causing the amygdala to be aroused, and the cortex to shut down.
Talk therapy cannot work, and can re-traumatise. You cannot counsel a lizard!

33. Brain Development and Neglect
Bruce Perry, MD, Ph.D. Baylor College of Medicine

34. Trauma and Attachment
Adults with unresolved trauma and loss may have difficulty in forming attachments
Green & Goldwyn (2002)
Children who fail to make secure attachments are more vulnerable to the effects of trauma

35. Rossie YP triggers What triggers have you noticed in YP at Rossie?
Do you have a sense of what each type of original Trauma (s) this may have connected to?

36. Rossie files: Identified triggers
Perpetrator out of prison; peer comments about self or family; talking about feelings; parent not phone or turn up; perceived treated unfairly by adults;
Challenged by staff/parents for behaviour; repeatedly asked to do something; adults saying no when you ask for something; going into a new/large group or outside social space; parent into prison; contact with Mo.

37. Understanding Neurobiology within Secure Accommodation
Early childhood trauma – begins negative cascade in brain development
McLean – developing triune brain bottom up
Survival mode (dysregulation of the body’s nervous system)
Preoccupation with detecting threat/danger - allostatic load - psychological/physical illness due to (Ford, 2009)
Survival-oriented biological changes essential for survival in abuse contexts
Maintained in non-threatening contexts
The very survival biological changes and strategies that helped kids survive - long term MH difficulties (Thayer et al., 2009)

38. Traumatic stress pathways to Secure accommodation
Unspoken ‘survival code’ (street rules) vs. ‘social contract’ (e.g. fairness, justice)
Experience multiple violence/abuse/neglect/trauma - violation of social contract (no fairness)
Hijacked by impact of T on managing physiology, thinking, feeling & behaviour (committing offences, running away)
Absence of societal response - low rates of Child abuse prosecution compared to other crimes – (no justice)(Cross et el., 2003)
Not surprisingly YP apply different standards in decision-making and in action (Fagan & Piquero, 2004).
Neuro-biologically driven survival (e.g. safety, control) beats legality (behaviour within the laws?) or Establishment rules

39. Trauma-informed assessment
PTSD & Developmental Trauma
Trauma history analysis of files (exemplar)
Trauma history interviews (protocols)
Battery of measures – Impact of events (PTSD); Moods & Feelings (depression); SDQ (wider mental health difficulties); ADES (dissociation); Traumatic Grief (exemplars)
Challenges of assessment

40. Why assess T? Emerging goal to address original goals
Original goals for secure accommodation
Safety in community & in secure accommodation itself, justice for crimes, prevention of future criminality
Emerging goal
Address MH needs to address original goals

41. Barriers Lack of funding to access MH services
Lack of identification of MH needs coming into Secure
MH experts may be not be trained in T
Staff in secure rarely come trained in MH or substance misuse; not trained to see psycho-social needs; Only 1/3 referred on for psychiatric assessment; Only 40% received treatment for drug misuse (Grisso, 2007)
YP 85% not see MH services as important (Abram et al., 2008)
Parents feeling hopeless and not seek MH services (Bradshaw et al., 2006) & not recognise YP as having MH problem (Watson, 2009)

42. T lens premise
MH & Substance misuse left untreated - continuing risk to safety self, other YP and staff (many studies!)

43. Trauma-informed intervention
Trauma-informed milieu
Context & Challenges
Safety first & stabilisation
Self-regulation – attention; awareness; emotional- regulation & social connectedness
Trauma-specific interventions
Teaching Recovery Techniques programme
EMDR group protocol
EMDR & TF-CBT
Sensori-motor therapy

44. Definition – Self regulation
“an integrated set of abilities or skills that draw from both executive function and emotion regulation capacities which are interrelated and act in a collaborative manner when an individual engages in goal-directed behaviour” (Mezzacappa, and Beardslee, 2009)
Pivotal role - self-regulation in increased adaptive functioning across wide range of outcomes (e.g., social competence, academic achievement, maintaining or regaining emotional equilibrium)
Markers – “enhance capacity to cope with stressors without self defeating (e.g., impulsive, perseverative, aggressive) or interpersonally ineffective (e.g., callous, manipulative, defiant) attitudes and behavior (Compas, 2006)”.

45. Activity: Affect regulation as focus
Dilemmas faced by trauma-impacted youth and by vicariously and directly traumatized program staff and milieus are viewed as the result of a dysregulation of core self-regulatory competences (Ford, 2005)
How do you create an environment which enhancement of self-regulation? (attention, awareness, self & affect-regulation)
How respond to triggers?
How avoid triggering triggers?

46. Trauma- specific interventions
EMDR (Francine Shapiro)
tfCBT
Sensori-motor therapy (Pat Ogden)
Somatic experiencing therapy (Peter Levine)
Zone of tolerance - hyper and hypo-arousal (Pat Ogden)

47. Trauma-focused treatment model
Cognitive Restructuring
Therapeutic context
Systemic Work (e.g. family or school)
Stabilisation
Exposure
Resource development

48. Safety, Education and Stabilising
Safety and Educative intervention
Current safety
Psycho-education
Normalise triggers
Stabilising techniques (emotional dys-regulation)
Safe place
Reconnecting to resources
Yoga/Walking; Mindfulness; Grounding, Centering; Containment
Orienting; Boundary experiments
Survivors organisations

49. Activity: Special place
Safe/special Place – a moment ….
Deep breath after each step – deep breath in and relax
Image – peaceful place? deep breath in and relax
Emotions - Feel? deep breath in and relax
Body - Where feel it in your body? deep breath in and relax
Enhancement - Sensations - Colours, texture, temperature, sounds, smells? deep breath in and relax
Image, feelings and body – deep breath in and relax
Cue Word with image, feelings, body - deep breath in and relax
Self Cuing with step above

50. Activity: Reconnecting to resources
Connecting to resources – a time when you have achieved, sense of competence, confidence … a moment of joy …..
Deep breath after each step – deep breath in and relax
Image – peaceful place? deep breath in and relax
Emotions - Feel? deep breath in and relax
Body - Where feel it in your body? deep breath in and relax
Enhancement - Sensations - Colours, texture, temperature, sounds, smells? deep breath in and relax
Image, feelings and body – deep breath in and relax
Cue Word with image, feelings, body - deep breath in and relax
Self Cuing with step above

51. Activity: Intrusive memories - visual
TV screen – traumatic memory image
Black and white; Freeze frame moving picture; Rewind image play backwards slowly
Speed up slow down; Color; Fuzzy blurred picture; Change contrast so fades; Press off button
Hand and distance technique
Smaller and smaller and farther and farther away till into wall
Same in hand – into fist and pull hand behind back
Framing
Move frame around; Positive encounter image; Lock away the image
Imaginary helper into the image and change it anyway want
Switch off screen (Smith et al., 2002)

52. Intrusive Memories – auditory and olfactory
Auditory techniques
Tape recorder – traumatic sound
Down, up, softer, harsh …. - switch off
Olfactory
Herbs and essential oils small before
Small like a sound and manipulate
Use herbs and essential oils again

53. Arousal Psycho-education – body response…… Breath control
Muscle relaxation
Guided imagery
What thoughts have and coping self statements
What helps with getting to sleep – routines etc…
Activity scheduling – exercise and fun activities back into life – for sleep

54. Avoidance Graded exposure and relaxation Grading traumatic reminders
Ladder of easiest 1st
Self rating of fear and coping statements thermometer (Activity)
Get help from an adult
Drawing, writing, talking
Looking to the future

55. Staff issues: Some stressors
Diminishing Govt funding
Litigation context – organisations get trapped in self defensive mindset
Vicarious trauma – exposure in line of duty T assault, murder & suicide - daily moment to moment reality
Political and economic stressors, constraints and threats (perceived or otherwise)
Government, Local authority goals – reduction of negative behaviours rather than growing YP competency , substance misuse, anger management, sexual offending - may miss target focusing on outcomes than disturbance
May emphasise control rather than relationship building and reilience
Little knowledgede of T history & how respond to YP in distress

56. Vicarious trauma Definitions
Secondary stress - “behaviours and emotions resulting from knowing about a traumatizing event experienced by a significant other. It is the stress resulting from helping or wanting to help a traumatized or suffering person - compassion fatigue” (Figley, 1995)
Burn out – “emotional overload and emotional exhaustion, characterized by depersonalization and reduced personal accomplishment as a response to the chronic emotional strain of dealing extensively with other human beings” (Maslach,1982).
Vicarious trauma – “a transformation in the worker’s inner experience resulting from empathic engagement with clients’ trauma material. These effects are cumulative and permanent, and evident in professional and personal life” (Pearlman & Saakvitne, 1995).

57. Incidence and Prevalence
Disaster workers - 10% met full criteria for PTSD, reported moderate symptoms (Farrar, 2002). Adaptation depends on the interaction between the characteristics of the situation and individual.
Emergency service personnel - 12% indicated experiencing clinical levels of PTSD (Van der Ploeg and Kleber, 2003).
War journalists - 19% reported significantly greater levels of PTSD, depressive symptoms and alcohol consumption compared to their peers and lifetime prevalence rates of PTSD similar to rates in combat veterans (Feinstein, Owen and Blair, 2002).
Forensic interviewers – Organizational satisfaction had a moderate inverse relationship with burnout and a slight inverse relationship with secondary trauma (Brian et al., 2006).

58. Impact of vicarious trauma
Vicarious trauma - intrusive imagery and thoughts, avoidance and emotional numbing, hyper-arousal symptoms, somatisation, and physical and alcohol use problems (Ursano et al., 1999).
Working with trauma survivors may lead to changes in self-identity, world-view, spirituality and general psychological functioning (McCann & Pearlmann, 1999).
Trauma workers may experience a disruption in major beliefs regarding safety and personal vulnerability, benevolence of the world and feelings of powerlessness (Janoff-Bulman, 1999).
Anecdotal and based on few empirical studies (Sabin-Farrell & Turpin, 2003).

59. Psychological Debriefing
Psychological Debriefing (PD) has been widely used with many different populations
Studies of effectiveness vary in quality but overall are poor
Group PD poorly investigated
Available evidence provides little evidence that early PD prevents psychopathology following trauma but is largely well received by participants
(Rivers Centre)

60. NICE Guidelines 2004
“ Where symptoms are mild and have been present for less than 4 weeks after the trauma, watchful waiting, as a way of managing the difficulties presented by individual sufferers, should be considered by healthcare professionals. A follow up contact should be arranged within 1 month”.

61. Protective factors High sense of purpose
High level of training and supportive supervision
Trained in trauma informed lens – know what to expect
Experience and age
Organisation viewed as supportive
Self care & know when to seek help
Childhood with little trauma
(McSwain, Robinson and Panteluk, 1998)

62. Personal/Professional Self Care
Recognize vicarious trauma is an occupational hazard
Accept your reactions as normal
Limit exposure to traumatic material (books, conferences, movies)
Develop a supportive environment for discussing your reactions
Engage in self care, self nurturing, physical health & leisure activities
Seek emotional and instrumental support
Take mental health breaks purposely
Seek out experiences which instil hope and comfort
Set clear boundaries between home and work

63. Organisational Care
Recognize vicarious trauma is an occupational hazard & de-stigmatize
Create a safe, private and down time spaces
Provide adequate pay & benefits as resources for dealing with stress
Provide supervision and consultation
Create a working environment that is respectful
Provide adequate vacation, sick time and personal leave
Provide professional development
Provide access to critical stress management support
Avoid over working staff to maintain emotional regulation
(McSwain, Robinson and Panteluk, 1998)

64. Coping with traumatised children
Activity: In pairs –
How do you cope with the pain and suffering of others?
How do you switch off when you go home?
What are your self-care strategies?

65. Useful Websites David Baldwin’s trauma pages
Bruce Perry’s Trauma Academy
Bessell van der Kolk - Trauma centre at JRI
EMDR UK & Ireland
UK Psychological Trauma Society
ESTSS & ISTSS