Richard Cross, CareVisions Group

http://www.carevisions.co.uk

UKCP Registered PsychotherapistUKCP Registered Psychotherapist

Member Counselling Society (Accredited) Member Counselling Society (Accredited)

e-mail: info@carevisions.co.uk telephone: 08700 428889

Outline of PresentationOutline of Presentation

Why Look at the effects of trauma?Why Look at the effects of trauma? What are the affects?What are the affects? What can we do to help?What can we do to help? What if we do nothing?What if we do nothing? SummarySummary

Indications of the Problem…Indications of the Problem…Child Protection RegistersChild Protection Registers

YEAR ENDED 31 MARCH 2002:YEAR ENDED 31 MARCH 2002: 2,018 Children (0-15 yrs / 2.1 per 2,018 Children (0-15 yrs / 2.1 per

1000)1000)(Scottish Executive),(Scottish Executive),

Year ended 31Year ended 31stst March 2001: March 2001: 26,840 – England, 26,840 – England, 2,126 – Wales, 2,126 – Wales, 1,414 – Northern Ireland 1,414 – Northern Ireland (Department of Heath)(Department of Heath)

Why Study Trauma?Why Study Trauma?

Numerous studies link trauma and criminal Numerous studies link trauma and criminal behaviour.behaviour.

Mann (1995) – Found 74% of a small sample Mann (1995) – Found 74% of a small sample of adolescents offenders held with secure of adolescents offenders held with secure conditions were experiencing symptoms conditions were experiencing symptoms consistent with PTSD. consistent with PTSD.

Dissociation is a common component of the Dissociation is a common component of the complex trauma response (van der Kolk et complex trauma response (van der Kolk et al., 1996)al., 1996)

Boswell (1995) - Boswell (1995) - Amongst those committing Amongst those committing the most serious of crimes, over 90% the most serious of crimes, over 90% experienced childhood trauma in the form of experienced childhood trauma in the form of abuse and/or loss and frequently both.abuse and/or loss and frequently both.

Why Study Trauma?Why Study Trauma?

Burgess et al (1987) - found a link Burgess et al (1987) - found a link between sexual abuse and the occurrence between sexual abuse and the occurrence of drug abuse, juvenile delinquency and of drug abuse, juvenile delinquency and criminal behaviour a few years later.criminal behaviour a few years later.

Steiner et al found 32% of incarcerated Steiner et al found 32% of incarcerated juvenile delinquents met the criteria for juvenile delinquents met the criteria for current PTSD, and - For 5% of the sample current PTSD, and - For 5% of the sample the symptoms of PTSD resulted from the the symptoms of PTSD resulted from the violence they perpetrated on others.violence they perpetrated on others.

Dissociation may mediate the ‘cycle of Dissociation may mediate the ‘cycle of violence’ – research indicates pathological violence’ – research indicates pathological dissociation in adolescent offenders 14.3 – dissociation in adolescent offenders 14.3 – 28.3 % (Moskowitz, 2004)28.3 % (Moskowitz, 2004)

What inference might we make from the What inference might we make from the following research on the needs of looked following research on the needs of looked after children?after children?

•45% were assessed as having a mental disorder•38% had clinically significant conduct disorders•16% were assessed as having emotional disorders – anxiety and depression•10% were rated as hyperactive

(Meltzer et al, 2004) Scottish Executive study

The truth?The truth?

These mental health indicators are symptoms relating to complex trauma and dissociative disorders (Terr, 1991; Putman, 1993).

‘

All truth passes through three stages.

First, it is ridiculed. Second, it’s violently opposed. Third, it’s accepted as self-evident’.

(Schopenhauer, 2006)

The TruthThe Truth

For many centuries various For many centuries various theorists and clinicians have theorists and clinicians have postulated about the psychological postulated about the psychological and emotional distress observed in and emotional distress observed in children and some began to children and some began to attribute some of the causes to attribute some of the causes to early childhood experiences of early childhood experiences of neglect and trauma…neglect and trauma…

The TruthThe Truth

This notion and sense of ‘truth’ could This notion and sense of ‘truth’ could be viewed as going through a process be viewed as going through a process of being ridiculed and violently of being ridiculed and violently opposed, but recent there appears to opposed, but recent there appears to have been an ‘tidal change’ in that have been an ‘tidal change’ in that society is more able overcome the society is more able overcome the defensive reactions to such notions to defensive reactions to such notions to begin to develop appropriate support begin to develop appropriate support and services for survivors e.g. Scottish and services for survivors e.g. Scottish National Strategy for Survivors of National Strategy for Survivors of sexual abuse. sexual abuse.

The 5 Symptoms of Post Traumatic The 5 Symptoms of Post Traumatic Stress Disorder (PTSD) in childrenStress Disorder (PTSD) in children

Re-experiencing the trauma in various Re-experiencing the trauma in various ways ways

Numbing of responsiveness and Numbing of responsiveness and avoidance of reminders of the traumaavoidance of reminders of the trauma

Hyper-arousalHyper-arousal Development of NEW fears Development of NEW fears that that

weren't present before the traumaweren't present before the trauma Development of aggressive behaviour Development of aggressive behaviour

that wasn't present before the traumathat wasn't present before the trauma

Trauma Symptoms and Trauma Symptoms and Conduct DisorderConduct Disorder

AggressioAggressionn

ImpulsivityImpulsivity Impaired Impaired

empathyempathy AngerAnger Disregard Disregard

for the for the futurefuture

Substance Substance abuseabuse

Risk-Risk-seeking seeking behaviourbehaviour

ReactivityReactivity

Do you only see the Do you only see the behaviour?behaviour?

Trauma, attachment and Trauma, attachment and Dissociation.Dissociation.

The three strands of The three strands of understanding which are understanding which are needed to inform effective needed to inform effective evidence based approaches for evidence based approaches for children referred to residential children referred to residential care?care?

An orphaned hippopotamus (1 year old) after a tsunami, was protected and formed an attachment with a 110 year old giant tortoise.

““Human beings of all Human beings of all ages are found to be at ages are found to be at their happiest and to their happiest and to be able to deploy their be able to deploy their talents to best talents to best advantage when they advantage when they are confident that, are confident that, standing behind them, standing behind them, there are one or more there are one or more trusted persons who trusted persons who will come to their aid will come to their aid should difficulties should difficulties arise”.arise”.

John Bowlby (1973, p 359)John Bowlby (1973, p 359)

““Maintenance of Maintenance of proximity to caregivers proximity to caregivers increases the likelihood increases the likelihood that the infant will be that the infant will be sheltered from sheltered from exposure to the exposure to the elements, defended elements, defended against attacks…”against attacks…”

Hesse, Main, Abrams & Rifkin, 2003Hesse, Main, Abrams & Rifkin, 2003

Grand Central – The Grand Central – The BrainBrain

Genes provide ‘Blueprints’ and basic Genes provide ‘Blueprints’ and basic framework of the brain,framework of the brain,

The Environment provides the shaping The Environment provides the shaping and finishing,and finishing,

‘‘They work in tandem, with genes providing They work in tandem, with genes providing the building blocks, and the environment the building blocks, and the environment acting like an on-the-job foreman, acting like an on-the-job foreman, providing instructions for the final providing instructions for the final construction….Sounds, sights, smell, construction….Sounds, sights, smell, touch – like little carpenters – all can touch – like little carpenters – all can quickly change the architecture’ quickly change the architecture’

Ronald Kotulak (1993)Ronald Kotulak (1993)

““The Dyadic Dance”The Dyadic Dance”

The caregiver modulates the infants The caregiver modulates the infants non-optimal states by calming the infant non-optimal states by calming the infant when arousal is too high and when arousal is too high and stimulating it when arousal is low. He or stimulating it when arousal is low. He or she is constantly attuned to and she is constantly attuned to and responding to the infants cues……responding to the infants cues……

(Schore,2001)(Schore,2001)

This is the dyadic dance. The adult is This is the dyadic dance. The adult is the interactive regulator of arousalthe interactive regulator of arousal

Modes of self-regulationModes of self-regulation

Interactive regulationInteractive regulation: involves the ability : involves the ability to utilise relationships to mitigate breaches in to utilise relationships to mitigate breaches in the window of tolerance and to either the window of tolerance and to either stimulate or calm oneself,stimulate or calm oneself,

Auto-regulationAuto-regulation: is the ability to self : is the ability to self regulate, independent of other people. It is the regulate, independent of other people. It is the ability to calm oneself down when arousal ability to calm oneself down when arousal arises to the upper limits of the window of arises to the upper limits of the window of tolerance or to stimulate oneself when arousal tolerance or to stimulate oneself when arousal drops to the lower limitsdrops to the lower limits

Ogden, 2002Ogden, 2002

Childhood Attachment StrategiesChildhood Attachment Strategies

Secure attachmentSecure attachment: infant shows clear : infant shows clear preference for interactive regulation, but preference for interactive regulation, but after being re-regulated by caregiver, is after being re-regulated by caregiver, is then able to self-regulate for short then able to self-regulate for short periodsperiods

Anxious attachmentAnxious attachment (also referred to as (also referred to as Insecure –ambivalent): the infant Insecure –ambivalent): the infant anxiously seeks proximity to the anxiously seeks proximity to the caregiver, cannot auto-regulate without caregiver, cannot auto-regulate without the caregiver and is not self soothed by the caregiver and is not self soothed by reunion.reunion.

Childhood Attachment StrategiesChildhood Attachment Strategies

Avoidant attachment Avoidant attachment (also referred to as (also referred to as Insecure –avoidant): : infant shows clear Insecure –avoidant): : infant shows clear preference for self regulation, often preference for self regulation, often actively avoiding interactive regulation actively avoiding interactive regulation and preferring books and toys to and preferring books and toys to caregivercaregiver

Disorganised attachmentDisorganised attachment: infant has : infant has difficulty with both interactive and auto-difficulty with both interactive and auto-regulation, exhibiting proximity-seeking regulation, exhibiting proximity-seeking coupled with freezing, distancing or coupled with freezing, distancing or avoidant behaviouravoidant behaviour

Disorganized AttachmentDisorganized Attachment

Secure attachment contributes to lifelong Secure attachment contributes to lifelong abilities to regulate emotional states. Even abilities to regulate emotional states. Even “anxious” and “avoidant” attachment styles “anxious” and “avoidant” attachment styles allow for predictable ways of regulating arousal, allow for predictable ways of regulating arousal, using either interactive or auto-regulatory using either interactive or auto-regulatory strategies.strategies.

Disorganized attachment status, on the other Disorganized attachment status, on the other hand, interferes with the development of hand, interferes with the development of bothboth auto- and interactive regulatory abilitiesauto- and interactive regulatory abilities

Disorganized attachment in children is Disorganized attachment in children is correlated with maternal behaviour which is correlated with maternal behaviour which is characterised as “frightening” or “frightened”. characterised as “frightening” or “frightened”. (Liotti, 1999)(Liotti, 1999)

Disorganized AttachmentDisorganized Attachment

In studies of abuse and neglected In studies of abuse and neglected children, disorganized attachment styles children, disorganized attachment styles have been found in over 80% of have been found in over 80% of maltreated children (Carlson et al, 1985; maltreated children (Carlson et al, 1985; Ogawa, 1997)Ogawa, 1997)

Disorganized attachment is also Disorganized attachment is also statistically significant predictor of statistically significant predictor of dissociative symptoms by age 19 and dissociative symptoms by age 19 and diagnoses of Borderline Personality diagnoses of Borderline Personality Disorder and Dissociative Identity Disorder and Dissociative Identity Disorder (Lyons –Ruth, 2001)Disorder (Lyons –Ruth, 2001)

The Trauma MechanismThe Trauma Mechanism

Other mental Other mental health problemshealth problems

(Co-morbidity)(Co-morbidity)

e.g. Major Depressive e.g. Major Depressive Disorder 48%Disorder 48%

Physiological Physiological responseresponse

Behavioural Behavioural re-enactmentre-enactment

Developmental Developmental impactimpact (Mal)adaptive (Mal)adaptive

coping strategiescoping strategies

Belief systemBelief system

TraumaTrauma

Behavioural Re-Behavioural Re-enactmentenactment

Young people can expose themselves, Young people can expose themselves, seemingly compulsively, to situations seemingly compulsively, to situations reminiscent of the original trauma.reminiscent of the original trauma.

In behavioural re-enactment of the In behavioural re-enactment of the trauma the characters may play the role trauma the characters may play the role of : of : victim/perpetrator/rescuervictim/perpetrator/rescuer. .

Three key ways: Harm to Others; Self-Three key ways: Harm to Others; Self-destructiveness; Re-victimization. destructiveness; Re-victimization.

Children seem more vulnerable than Children seem more vulnerable than adults to compulsive behavioural adults to compulsive behavioural repetition and loss of conscious memory repetition and loss of conscious memory of the trauma.of the trauma.

Key conceptsKey concepts

Behaviour is seen as being related to Behaviour is seen as being related to either Hyper-arousal or Hypo-arousal – either Hyper-arousal or Hypo-arousal – related to either attachment and / or related to either attachment and / or trauma disorders (Cross, 2005)trauma disorders (Cross, 2005)

Based on sound neurological research Based on sound neurological research about the impact of trauma, attachment about the impact of trauma, attachment and neglect,and neglect,

The use of social milieu and the The use of social milieu and the therapeutic residential care staffs therapeutic residential care staffs interactions with the child can help interactions with the child can help regulate the child behaviour (symptoms regulate the child behaviour (symptoms of trauma),of trauma),

Key ConceptsKey Concepts

No child who has experienced trauma is No child who has experienced trauma is going to heal and learn to use different going to heal and learn to use different ways of coping without first feeling secure, ways of coping without first feeling secure,

For children who have experienced For children who have experienced chronic trauma, the importance of chronic trauma, the importance of environmental interventions can not be environmental interventions can not be overemphasised and is viewed as overemphasised and is viewed as essential (Shirar, 1996, p 146), in terms of essential (Shirar, 1996, p 146), in terms of providing the stable and safe place from providing the stable and safe place from which therapeutic work can be undertaken which therapeutic work can be undertaken (milieu e.g. understanding of parallel (milieu e.g. understanding of parallel processes etc throughout organisation). processes etc throughout organisation).

Example of structures to help (must be done for all Example of structures to help (must be done for all elements of trauma mechanism - hyperarousal etc ): elements of trauma mechanism - hyperarousal etc ):

Strategies for Traumatic Re-enactmentStrategies for Traumatic Re-enactment

Children and Young people:- Redirection of Traumatic Scenario- Life Space Interview (provide opportunity

to develop insight)- Safety Planning- Trauma Work

Staff & Program:- Staff Training- Debriefing- Focus on Self Awareness

Theory into PractiseTheory into PractiseHyper-arousal (aggression, impulsive behaviour, Hyper-arousal (aggression, impulsive behaviour,

children viewed as high risk, emotional and children viewed as high risk, emotional and behavioural problems – ‘Fight or flight’ responsebehavioural problems – ‘Fight or flight’ response))

Window Window

OfOf

ToleranceTolerance

Hypo-arousal (dissociation, depression, self harm Hypo-arousal (dissociation, depression, self harm etc)etc)

If Child Is Experiencing High Arousal we If Child Is Experiencing High Arousal we need to show Low Arousal – Common sense need to show Low Arousal – Common sense that can be difficult in practisethat can be difficult in practise A non-confrontational way of managing A non-confrontational way of managing

challenging behaviourchallenging behaviour A philosophy of care which is based on A philosophy of care which is based on

valuing peoplevaluing people An approach that specifically attempts to An approach that specifically attempts to

avoid aversive interventionsavoid aversive interventions An approach that requires staff to focus on An approach that requires staff to focus on

their own responses and behaviour and not their own responses and behaviour and not just locate the problem in the person with just locate the problem in the person with the labelthe label

A collection of strategies that are designed A collection of strategies that are designed to rapidly reduce aggressionto rapidly reduce aggression

ASSUMPTION ONEASSUMPTION ONE

Most people who are challenging are usually extremely Most people who are challenging are usually extremely hyper-aroused at the time. We should therefore avoid hyper-aroused at the time. We should therefore avoid doing anything that will arouse a person who is already doing anything that will arouse a person who is already upset.upset.

ASSUMPTION TWOASSUMPTION TWO

A large proportion of challenging behaviours are usually A large proportion of challenging behaviours are usually preceded by demands and requests, therefore reducing preceded by demands and requests, therefore reducing these should help to reduce the frequency and perhaps these should help to reduce the frequency and perhaps the intensity of the incidents.the intensity of the incidents.

ASSUMPTION THREEASSUMPTION THREE

Most communication is predominantly non-verbal, Most communication is predominantly non-verbal, therefore we should be aware of the signals we therefore we should be aware of the signals we communicate to people who are upset.communicate to people who are upset.

Theoretical Assumptions

One technique to take away: life space One technique to take away: life space interviews… using a technique to increase interviews… using a technique to increase coping and understandingcoping and understanding

The following is a brief overview of an The following is a brief overview of an approach initially developed for work with approach initially developed for work with high risk adolescent but has been found to high risk adolescent but has been found to work well with children… work well with children…

Other approaches can be added to this to Other approaches can be added to this to increase outcomes which I developed as increase outcomes which I developed as part of a set of therapeutic techniques for part of a set of therapeutic techniques for working with adolescents. I will be running working with adolescents. I will be running in future workshops on these in the future in future workshops on these in the future e.g. advanced role play strategies.e.g. advanced role play strategies.

Using Drawing – with high Using Drawing – with high risk adolescentsrisk adolescents

Simple is best,Simple is best, Let young person create own Let young person create own

symbols,symbols, Remember safety must be in place Remember safety must be in place

first,first, Young person has developed self Young person has developed self

care strategies,care strategies, Remember, at times process might Remember, at times process might

need to return to stabilisation phase.need to return to stabilisation phase.

What was happening around What was happening around meme

What was I thinkingWhat was I thinking

What was I feeling?What was I feeling?

How it is all put together…How it is all put together…

6/10

If I don’t hit him first he will hit me!

Walking down street and see ‘Joe… who I don’t like.

He is laughing at me.

Conclusion:Conclusion: Link between trauma and attachment Link between trauma and attachment

styles in ability to regulate affect, styles in ability to regulate affect, Importance of being able to help child Importance of being able to help child

learn how to regulate affect,learn how to regulate affect, Links between trauma and long term Links between trauma and long term

consequences for not only the child but consequences for not only the child but society,society,

Proposal to utilise knowledge and Proposal to utilise knowledge and understanding relating to trauma and understanding relating to trauma and attachment to create evidenced based attachment to create evidenced based approaches to meet the needs of young approaches to meet the needs of young people for whom residential care has not people for whom residential care has not address such underlying needs (e.g. address such underlying needs (e.g. limited specialised provision in Scotland)limited specialised provision in Scotland)

The need total organisation approach to The need total organisation approach to therapeutic residential caretherapeutic residential care

What we need to be aware of..What we need to be aware of.. Residential child care can replicate the toxic traumatic Residential child care can replicate the toxic traumatic

experiences of children who are looked after e.g. experiences of children who are looked after e.g. multiple placement breakdown,multiple placement breakdown,

Those responsible for identifying care for children need Those responsible for identifying care for children need to understand the high level of skill, support and to understand the high level of skill, support and resilience required by the caregiver to ‘survive’ to resilience required by the caregiver to ‘survive’ to enable improved outcomes,enable improved outcomes,

To be able to use the relationship the staff member To be able to use the relationship the staff member has with the child is crucial but to do so effectively, the has with the child is crucial but to do so effectively, the individual needs to be able to work within a individual needs to be able to work within a therapeutic framework of understanding which therapeutic framework of understanding which contains not only the work but which directs and contains not only the work but which directs and maintains an understanding of what we do and how we maintains an understanding of what we do and how we do it for all those who work within the organisation.do it for all those who work within the organisation.

Unfortunately to educate on such areas take time and Unfortunately to educate on such areas take time and groups and teams can sometimes neglect such areas groups and teams can sometimes neglect such areas for short term gain…. Above all it takes time to not only for short term gain…. Above all it takes time to not only develop a culturally sensitive environment to develop a culturally sensitive environment to undertake trauma informed therapy but also the undertake trauma informed therapy but also the development of an appropriately trained staff groupdevelopment of an appropriately trained staff group

If we do nothing…… the Legacy?If we do nothing…… the Legacy?

• Increase in distress

•Higher Criminal Justice costs.

•We will be letting our children down

•We won’t be doing everything we can to stop victimisation,

•Higher society costs (Mental health, Health, social services).

•What might lay ahead for the ‘children of the children’ – intergenerational transmission.

The Future can be The Future can be differentdifferent