1. Psycho-trauma and Recovery Across Scotland’s Secure Estate Dr Ian Barron Reader in Trauma Studies, University of Dundee & Ms Jen Copley Forensic Psychologist

2. Take Home Message Trauma is pervasive in our caseloads and institutions we work with (children and adults); however lack of ‘trauma’ lens Phase approach and progressive counting - possible approach for trauma processing

3. 2 Part Presentation Phase 1 – extent and nature of trauma in secure care & TRT evaluation Phase 2 - TPB across the secure estate - therapist experience & experiential activity

4. Shift focus - behaviour management to addressing underlying trauma (drives behaviour & results in YP unresponsive to behaviour programmes) Introduce trauma-specific screening & evaluation (i) Developmental trauma framework to case files analysis (i) Trauma history interview (iii) Trauma-specific measures (PROPS & CROPS) Training in trauma specific programmes & trauma- sensitive milieu Project aims (Phase 1 and 2)

5. Phase 1 Pilot Project N=17; 14-18yrs; 11 female/6 male; Scottish Caucasian; Relative & absolute poverty; poor quality housing/homeless (n=2); parental prostitution (n=5); drug dealing (n=3); substance misusing (n=11); schedule 1 offenders access to home (n=3), mother sectioned under the mental health act (n=1) In free fall, e.g. 40 absconding, 20 break ins, 7 assaults, 3 suicide attempts ….. short period of time.

6. Case file analysis Trauma invisible in medical files Physical rather than mental health focus No connection - embodied symptoms & YP trauma ‘Scatter Gun’ of professional involvement Up to 31 different types of professional per YP – frequent changes Omission of survivor organizations

7. Extensive abuse histories not set within trauma lens 10 types categorized sexual abuse (n=12); physical abuse (n=15); physical assault (n=17); experiencing domestic violence (n=12); witnessing domestic violence (n=8); neglect (n=10); emotional abuse (n=7); hospitalisations (n=9); sudden traumatic losses (n=17); and frequent placement change (n=17). Few coherent chronologies (n=4) - despite repeated child death recommendations

8. Lack of Social Justice for YP vs. multiple legal proceedings Despite extensive abuse only 1 YP experienced justice through Scottish Legal system for harms done to them Vs. YP experienced multiple police stations, over-night custody, charges, child protection case conferences, children’s panels, review meetings, supervision meetings, care plan meetings …

9. PTSD unrecognised & triggers not connected to historical abuse Descriptive behaviours - hostility, self-harm, drug taking etc. Omission YP internal intrusive/sensory experiences Few PTSD assessments & no diagnosis as YP “unpredictable” - invalidating? 8 files recognised daily events as behavioural triggers – e.g. derogatory comments to YP

10. Developmental T symptoms apparent but not seen as consequences of T Extensive behavioural difficulties, charges Severely disrupted educational histories Violent family & peer relationships Little to no hope for future Emotional dys-regulated Disturbed cognitions (rarely reported) Re-victimisation statements (frequent) Dissociation (n=2) - no evidence professionals making connection between substance misuse/self-harm Depression rarely named (n=3) – yet symptoms reported.

11. Conclusion: file analysis PTSD & developmental trauma symptoms pervasive with YP in secure care – no assessment Professional reports indicate lack of understanding of the impact of trauma on YPs presenting behavioural difficulties No trauma-specific programmes Health/welfare services need to understand: (i) the nature of children’s T experience (ii) how to respond appropriately

12. What did the young people say – Trauma history interviews events and SUDs 0-10 9 T events on average; multiple 10s - cumulative Ts not processing Multiple T losses: deaths, self/sibling into care, parent in prison Violence endemic: gang, assaults experienced and done Agency traumas: returned to abusive home; hearings; in custody; into care (esp. 1 st time); secure accommodation No harm conducting trauma histories – psycho- education

13. Compared with standardised measures Clinical levels (mostly clusters) of: PTSD/Complicated Grief (65%) Depression (65%) Dissociation (18%) yet signs found in nearly all young people (files) Underestimated trauma as measures developed around ‘single’ events

14. Manualised Programme intervention Group-CBT ‘Teaching Recovery Techniques’ (TRT) Coping Skills - Intrusion/Arousal/Avoidance Children and War Foundation - Patrick Smith, Bill Yule & Atle Dyregrov

15. Evaluation (RCT) of TRT YP (N=17) Presenters PSDO team (n=3) Trauma history interview SUDs; standardized measures (CRIES-13; MFQ; ADES; TGIC; SDQ) 2 weeks pre/post TRT Programme fidelity – video analysis Interviews YP; Staff focus group

16. TRT Findings Large effect size - reducing SUDs Small effect size - behavioural change No statistical difference - standardised measures YP mostly positive & identified specific helpful strategies Presenters (i) YP selection and grouping important (ii) liaison with care/education staff to transfer YP strategies (iii) further gains after evaluation Programme fidelity high Substantial financial post-placement gains achieved for some YP. Whole staff group - substantial knowledge gains in T-sensitive environments

17. Phase 2 – Why TPB? Privacy - Some harm inappropriate to disclosure in group Individual therapy - standard of care for T (NICE) Short duration placement impeding group delivery Intensive – sessions lasts as long as YP can On site therapy - immediate access to treatment Phase model enables high levels of engagement/lasting change Manualised/replicable & develop with in-care populations Cost saving - time limited behavioural stabilization to intensive trauma focused treatment

18. Practitioner perspective Limitations of other treatment approaches Targets all behaviours of concern Client led, but with clear structure Use of imagery Provides privacy for client

19. Programme overview StandardTPBFairy Tale Working alliance Getting to know you Once upon a time… InformationHistory/Worst list The knight and the kingdom Goals /Motivation Future moviesIdentify the Princess FormulationTreatment Contracting The Plan StabilisationSafety and Stabilisation Fence around Skill development Skill Building/Strength building Personal training Address trauma Trauma Resolution Slay the dragons GeneralisationConsolidation of gainsMarry the princess Relapse Prevention Relapse Prevention and harm reduction Training future dragon-slayers Plant trees

20. Progressive Counting Asks the client to go over the trauma in their mind, starting at a point before the trauma and ending when the ‘worst bit’ is all over You determine the start and end points- Time/Place/Action; but not required to discuss the trauma in any detail Therapists counts, first from 1-10, then increasing by 10 each time … This continues until SUDS down to 0

21. Structured approach All sessions scripted Start and end each session in same way During ‘getting to know you’ and ‘history’ section, no follow up questions Lots of the exercises use imagery and ask the client to image situations-this encourages the client to imagine the actions they will take and not just the final goal After treatment planning select sessions based on individual needs

22. Future Movies In pairs work through the future movie session Practice using the script Practice the imagery exercise With the final scene - need time, place and action

23. Webpages and reference lists Children and War Foundation - www.childrenandwar.org www.childrenandwar.org Ricky Greenwald (Child Trauma Institute) - www.childtrauma.com www.childtrauma.com Bessell van der Kolk – www.traumacenter.org/about/about_bessel.php www.traumacenter.org/about/about_bessel.php Francine Shapiro (EMDR) – www.emdr.com/francine-shapiro-phd.html www.emdr.com/francine-shapiro-phd.html

24. Thank You Ian Barron i.g.z.barron@dundee.ac.uk Jen Copley jen.copley@kibble.org