1. Scotland’s Secure Estate: Healing Trauma Dr. Ian Barron Reader in Trauma Studies University of Dundee

2. Dr Ian Barron, UoD Scotland’s Secure Estate (ESS; Good Shepherd; Kibble; Rossie; St Mary’s) Dr Ricky Greenwald, Child Trauma Institute Dr Bill Yule, Dr Atle Dyregrov and Dr Patrick Smith, Children and War Foundation. David Cotterell - A Scottish Government funded project

3.  TM burnt in under severe threat & extreme emotion  Triggered by – sensory fragments similar to original trauma, e.g. talking about T; seeing similar face, hearing voice, smell of aftershave, taste …  Re-experienced (not re-remembered) in same vividness; body sensations, horror, terror, helplessness as original event; as if ‘happening again’  Neocortex & mammalian brain go off line  Language centre (Brocas area) goes off-line  Activated - re-traumatizes; timeless and immutable; sense of it always in the present; life through trauma lens of terror/helplessness; highly accurate (sensory)  Generalised response - Amygdale: smart smoke alarm “a raised hand becomes a punch” (Myers, 2009)  Bottom up rather than top down processing

4.  Safety first; “safe now”; good attachment  Stabilization – calming and dissociation techniques - improved affect regulation  Core relationship factors – empathic, warm, respectful, shared understanding & planning  Motivational interviewing (bounce effect)  Trauma-specific therapies – “face T memory & not overwhelmed, brief exposure, viewing distance, broader perspective, internal processing, dual focus, privacy option, coherent structured narrative”

5.  Prolonged exposure – old standard, tell story in detail over and over, - ordeal teenagers as revs up anger/guilt  Trauma-focused CBT – write/draw story page by page in a book, piece by piece structure narrative, lot of lab research applied to community MH settings, 8-10 sessions per TM  Narrative Exposure Therapy (KidNET), dev with refugees, tell life story with trauma story embedded, rope timeline - stones/flowers, individual & group (4-6 sessions)  Traumatic Incident Reduction – guided through imagining the T story 1 to 3 sessions per TM  Eye Movement Desensitization Reprocessing – new standard, focus on worst moment during eye movements, brief exposure, associative memory (1-3 sessions?)  Progressive Counting – imagine the movie while therapist counts to 100; T memory sandwiched between positive past and future images – contains associative memory (intensive sessions – couple of days!)  (Greenwald, 2014)

6.  A framework for analysing dev. trauma in professionals’ reports/case files  Quantified extent of PTSD & Developmental trauma in Scotland’s SE  Quantified co-morbid symptoms of depression, traumatic grief & dissociation – battery of T measures to choose from  An efficient trauma history interview (30-40 mins) where adolescents disclose 9-11 T events

7.  Enabled training & supervision of staff in:  Brief exposure therapy (individuals)  Transformational healing to occur  Deliver group-based CBT coping skills programme – PTSD coping skills utilised with staff support  Care & education staff Psycho- education training

8.  Staff who can train other staff in TRT  Innovative use of TRT, e.g. beyond programmes staff/suicide prevention  Started to benchmark through dev. trauma measures & developed own spreadsheets  Cross provision T training, supervision and communication  T research partners RCT, cluster case studies, organisational case study – high impact journals – exploring rigor

9.  Unique examples  Qualitative interviews  Quasi-qualitative (degree of quantification)  Triangulation of adolescent/practitioner and manager data  Transparent data and analysis  Inter-rater reliability & open to reader contestability  It’s about next steps  ‘YOUR’ words; as ‘SE’ – not in individual prov.

10.  152; 12.10 to 18.05 years; average age15.6 years  Length of placement1 week to 4 years  Average length was 7 ½ months (n=132, SD = 7.00)  1month most frequent placement (n=19, 12.7%), followed by 4 months (n=18, 12%); 6 & 7 months (n=11, 7.3%); 3 months (n=10, 6.7%), 8 months (n=9, 6%); 2 months (n=5, 3.3%).  92 male and 43 female  1Asian female – home grown population  1/3 recorded, all non-disabled (?)

11.  9 T events on average; multiple 10s cumulative Ts not processing  Multiple T losses: deaths, into care, parent in prison, sibling into care;  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

12. Secure Estate  59% -77% (CROPS)  46% - 51% (PROPS)  Smaller no./inconsistent/bias at each re-test  Staff & adolescent awareness of T may have increased with T programmes? RCT PTSD (65%) Depression (65%) Dissociation (18%)

13.  Programme No. of adolescents% No. of sessions  TPB Not PCn = 27 18%8  TRT n=1812% 7  CBT n=10 7%6  DBT* n=2 2%-  Behaviour n=5939%9  No treatment n=3322%  -  *DBT = Dialectical Behaviour Therapy  No significant difference across programmes

14.  Transformational healing - considerable easing of distress  New sense of identity linked to hopeful future  Desire to avoid a bad ending to their lives  Remarkable extent adolescents internalised/express in words therapeutic process of change  Rated each treatment phase highly, suggesting cumulative nature of phase approach in preparing adolescents to cope with brief exposure therapy

15.  Two world leading programmes brief exposure / group- based coping skills  Transformational healingchanged sense of identity  Applying coping skills back in units (better fit - familiar/ challenges of brief exposure avoided enabling delivered with less qualified staff  Understanding T as underlying behaviour  Practitioner skills in T coping and processing;  Increase in psychologists & direct intervention time to adolescents;  Communication across secure estate;  T-specific engagement with stakeholders/ LA & adol. asking for T-informed treatments

16.  Practitioners stopped using TPB at level of novice (one or two cases) or beginner (no completed cases or a small number of completed cases)  No incremental introduction in trialling new skills involving less complex cases  Insufficient therapy time  Too few qualified staff  Myriad of work demands/feeling overwhelmed  Insufficient number of referrals  Short duration placements  Paradigm clash

17.  Position statements on trauma-informed practice (e.g. the Centre for Youth and Criminal Justice)  Reframed practice from a trauma lens (IVY)  National organisations - SE conference and seminar presentations, e.g. UK Psychological Trauma Society; EMDR; Forensic Psychologists Forum; CYCJ  Other organisations exploring TPB training (Barnardos/Scottish Prison).  Inspection of programmes teams  Clinical psychologists are delivering PC effectively (Forth Valley Health Board )

18.  Workers who communicate the message - adolescent of value & belief could make better future for themselves  No paradigm clash or practice beliefs to unlearn  Reasonable level of protocol adherence  Practitioner being led by ‘expert’ rather than collegiate guidance  Adolescent factors such as sufficient emotional intelligence and motivation.

19.  7 psychotherapists trained in progressive counting (PC).  100% of therapists have continued to deliver PC.  Over a 6 month period, delivered PC to completion to 60 adults  Included complex trauma from childhood abuse & clients who experienced abuse while ‘in care’

20.  Reduction in intrusive symptoms - nightmares, imagery and thoughts of guilt and worthlessness  Positive changes in negative beliefs, reduction of avoidance behaviours, improved mood, sleep and concentration, re-engagement in social activities  Team report to be very pleased with PC  “A valuable addition to their therapeutic repertoire. It is acceptable to patients, cost and clinically efficient and extremely effective”.  Only 3 non-responders (hadn’t responded to other therapies either)

21.  Clear strategic leadership that this is the way forward  Paradigm congruence with current models of therapy  Implementation of the programme on a daily basis  Group culture of support and experience of success to encourage persistence with difficult cases.

22.  Head of Units – T; T recovery and T-informed organizational issues  And supervision for care staff - developing and maintaining T-sensitive milieu, & feedback with prog. teams  Coping skills prog. (TRT) & brief exposure therapies (specialist team/ongoing training/supervision and accreditation (capacity build vs expert models)  T in transition meetings and report writing.  Across the SE  TRT trainer of trainers – sustainable model

23.  Utilise developmental trauma framework on professionals reports  Utilise T screening measures  Implement standardized T assessment measures for evaluation  ‘benchmarking’ of trauma-specific outcomes  Trauma history interviews very efficient  T Report writing  Keep recording spreadsheet – systematize recording

24.  Staff – vicarious trauma (training/supervision)  Families on how to cope with their own trauma /adolescent’s recovery  Stakeholders on trauma-informed assessment, trauma-sensitive milieu, trauma-informed practice and brief exposure therapies

25.  Need to increase direct therapeutic time for adolescents.  Provide adolescents ‘testimonials’  Specialised team of brief exposure trauma therapists

26.  Staff qualified and motivated to deliver brief exposure therapies.  Team of committed T staff to sustain each other  Not assume Forensic Psychologists want to do or support brief exposure

27.  ‘Between Hospital and Prison or thereabouts?’ (Harrid and Timms, 1995)  Within a competitive commercialized care context, with multiple stakeholders, there will be a need for secure care policy to be explicit in developing trauma-informed practice, trauma-sensitive milieu and brief exposure therapies.  Government child-related policies should state the value of developing trauma-informed understandings and practice.  Long term commitment to core & ‘connected’ issues (T) & Qs. vs secondary issues - sexual exploitation/substance misuse

28.  Dissemination - Journal Publications with each provision - Cluster Case Studies – TPB; Case study TPB; New practitioners case study – TRT; Case Study – suicide individual case – TRT; Cognitive dissonance paper; Forth Valley paper  Conferences/seminars  Provision/ UoD Websites; Facebook; Leaflets  Research – Unanswered Q; specialist team in US Juvenile Detention; Secure in Scotland  Training/Assessment/Psychoeducation (milieu/families etc)/Recruitment/Therapy– see recommendation slides  Policy development provision & national