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

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

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??

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)

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

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

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

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.

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

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)

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.

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

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

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

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

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)

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

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.

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

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.

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

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

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

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)

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.

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?

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

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)

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!)

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.

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.

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!

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

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

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?

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.

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)

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

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

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

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)

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

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

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)”.

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?

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)

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

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

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

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

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)

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

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

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

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

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).

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).

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).

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)

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”.

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)

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

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)

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?

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