psycho-trauma and recovery across scotland’s secure estate dr ian barron reader in trauma studies,...
TRANSCRIPT
Psycho-trauma and Recovery Across Scotland’s Secure Estate
Dr Ian BarronReader in Trauma Studies, University of
Dundee&
Ms Jen CopleyForensic Psychologist
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
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
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)
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.
Case file analysis
Trauma invisible in medical files Physical rather than mental health focusNo connection - embodied symptoms & YP
trauma
‘Scatter Gun’ of professional involvement Up to 31 different types of professional per
YP – frequent changesOmission of survivor organizations
Extensive abuse histories not set within trauma lens
10 types categorizedsexual 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
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 …
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
Developmental T symptoms apparent but not seen as consequences of T
Extensive behavioural difficulties, chargesSeverely disrupted educational historiesViolent family & peer relationships Little to no hope for future Emotional dys-regulatedDisturbed cognitions (rarely reported)Re-victimisation statements (frequent)Dissociation (n=2) - no evidence professionals making
connection between substance misuse/self-harmDepression rarely named (n=3) – yet symptoms
reported.
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 programmesHealth/welfare services need to understand:(i)the nature of children’s T experience(ii)how to respond appropriately
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. 1st time); secure accommodation
No harm conducting trauma histories – psycho-education
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
Manualised Programme intervention
Group-CBT ‘Teaching Recovery Techniques’ (TRT)
Coping Skills - Intrusion/Arousal/Avoidance
Children and War Foundation - Patrick Smith, Bill Yule & Atle Dyregrov
Evaluation (RCT) of TRT
YP (N=17) Presenters PSDO team (n=3)Trauma history interviewSUDs; standardized measures (CRIES-13;
MFQ; ADES; TGIC; SDQ)2 weeks pre/post TRTProgramme fidelity – video analysisInterviews YP; Staff focus group
TRT Findings
Large effect size - reducing SUDs Small effect size - behavioural changeNo statistical difference - standardised measuresYP mostly positive & identified specific helpful
strategiesPresenters (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
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
Practitioner perspective
Limitations of other treatment approaches
Targets all behaviours of concernClient led, but with clear structure
Use of imageryProvides privacy for client
Programme overviewStandard TPB Fairy Tale Working alliance
Getting to know you Once upon a time…
Information History/Worst list The knight and the kingdom
Goals /Motivation
Future movies Identify the Princess
Formulation Treatment Contracting The Plan Stabilisation Safety and Stabilisation Fence aroundSkill development
Skill Building/Strength building
Personal training
Address trauma
Trauma Resolution Slay the dragons
Generalisation Consolidation of gains Marry the princessRelapse Prevention
Relapse Prevention and harm reduction
Training future dragon-slayersPlant trees
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
Structured approach
All sessions scripted Start and end each session in same wayDuring ‘getting to know you’ and ‘history’
section, no follow up questionsLots 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
Future Movies
In pairs work through the future movie session
Practice using the scriptPractice the imagery exerciseWith the final scene - need time, place and
action
Webpages and reference lists
Children and War Foundation - www.childrenandwar.org
Ricky Greenwald (Child Trauma Institute) - www.childtrauma.com
Bessell van der Kolk – www.traumacenter.org/about/about_bessel.php
Francine Shapiro (EMDR) – www.emdr.com/francine-shapiro-phd.html
