Transcript Broken Bonds: - Home — Survivor Scotland

Richard Cross, CareVisions Group
http://www.carevisions.co.uk
UKCP Registered Psychotherapist
Member Counselling Society (Accredited)
e-mail: [email protected]
telephone: 08700 428889
Outline of Presentation
Why Look at the effects of trauma?
 What are the affects?
 What can we do to help?
 What if we do nothing?
 Summary
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Indications of the Problem…
Child Protection Registers
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YEAR ENDED 31 MARCH 2002:
2,018 Children (0-15 yrs / 2.1 per 1000)
(Scottish Executive),
Year ended 31st March 2001:
26,840 – England,
2,126 – Wales,
1,414 – Northern Ireland
(Department of Heath)

Why Study Trauma?
Numerous studies link trauma and criminal behaviour.
 Mann (1995) – Found 74% of a small sample of
adolescents offenders held with secure conditions
were experiencing symptoms consistent with
PTSD.
 Dissociation is a common component of the
complex trauma response (van der Kolk et al.,
1996)
 Boswell (1995) - Amongst those committing the
most serious of crimes, over 90% experienced
childhood trauma in the form of abuse and/or loss
and frequently both.
Why Study Trauma?
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Burgess et al (1987) - found a link between
sexual abuse and the occurrence of drug abuse,
juvenile delinquency and criminal behaviour a
few years later.
Steiner et al found 32% of incarcerated juvenile
delinquents met the criteria for current PTSD,
and - For 5% of the sample the symptoms of
PTSD resulted from the violence they
perpetrated on others.
Dissociation may mediate the ‘cycle of violence’
– research indicates pathological dissociation in
adolescent offenders 14.3 – 28.3 % (Moskowitz,
2004)
What inference might we make from the
following research on the needs of looked
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?

‘
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 Truth

For many centuries various theorists
and clinicians have postulated about the
psychological and emotional distress
observed in children and some began to
attribute some of the causes to early
childhood experiences of neglect and
trauma…
The Truth

This notion and sense of ‘truth’ could be
viewed as going through a process of
being ridiculed and violently opposed,
but recent there appears to have been
an ‘tidal change’ in that society is more
able overcome the defensive reactions
to such notions to begin to develop
appropriate support and services for
survivors e.g. Scottish National Strategy
for Survivors of sexual abuse.
The 5 Symptoms of Post Traumatic
Stress Disorder (PTSD) in children
Re-experiencing the trauma in various
ways
 Numbing of responsiveness and
avoidance of reminders of the trauma
 Hyper-arousal
 Development of NEW fears that weren't
present before the trauma
 Development of aggressive behaviour
that wasn't present before the trauma

Trauma Symptoms and
Conduct Disorder
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Aggression
Impulsivity
Impaired
empathy
Anger
Disregard
for the
future
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Substance
abuse
Riskseeking
behaviour
Reactivity
Do you only see the
behaviour?
Trauma, attachment and
Dissociation.
 The
three strands of understanding
which are needed to inform
effective evidence based
approaches for children referred to
residential 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 ages
are found to be at their
happiest and to be able
to deploy their talents
to best advantage when
they are confident that,
standing behind them,
there are one or more
trusted persons who will
come to their aid should
difficulties arise”.
John Bowlby (1973, p 359)
“Maintenance of proximity to
caregivers increases the
likelihood that the infant
will be sheltered from
exposure to the elements,
defended against
attacks…”
Hesse, Main, Abrams & Rifkin, 2003
Grand Central – The
Brain
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Genes provide ‘Blueprints’ and basic
framework of the brain,
The Environment provides the shaping and
finishing,
‘They work in tandem, with genes providing the
building blocks, and the environment acting
like an on-the-job foreman, providing
instructions for the final
construction….Sounds, sights, smell, touch –
like little carpenters – all can quickly change
the architecture’
Ronald Kotulak (1993)
“The Dyadic Dance”
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The caregiver modulates the infants nonoptimal states by calming the infant when
arousal is too high and stimulating it when
arousal is low. He or she is constantly
attuned to and responding to the infants
cues……
(Schore,2001)

This is the dyadic dance. The adult is the
interactive regulator of arousal
Modes of self-regulation
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Interactive regulation: involves the ability to
utilise relationships to mitigate breaches in the
window of tolerance and to either stimulate or calm
oneself,
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Auto-regulation: is the ability to self regulate,
independent of other people. It is the ability to calm
oneself down when arousal arises to the upper limits
of the window of tolerance or to stimulate oneself
when arousal drops to the lower limits
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Ogden, 2002
Childhood Attachment Strategies
Secure attachment: infant shows clear
preference for interactive regulation, but after
being re-regulated by caregiver, is then able
to self-regulate for short periods
Anxious attachment (also referred to as
Insecure –ambivalent): the infant anxiously
seeks proximity to the caregiver, cannot autoregulate without the caregiver and is not self
soothed by reunion.
Childhood Attachment Strategies
Avoidant attachment (also referred to as
Insecure –avoidant): : infant shows clear
preference for self regulation, often actively
avoiding interactive regulation and preferring
books and toys to caregiver
Disorganised attachment: infant has difficulty
with both interactive and auto-regulation,
exhibiting proximity-seeking coupled with
freezing, distancing or avoidant behaviour
Disorganized Attachment

Secure attachment contributes to lifelong abilities to
regulate emotional states. Even “anxious” and
“avoidant” attachment styles allow for predictable
ways of regulating arousal, using either interactive or
auto-regulatory strategies.
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Disorganized attachment status, on the other hand,
interferes with the development of both auto- and
interactive regulatory abilities
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Disorganized attachment in children is correlated
with maternal behaviour which is characterised as
“frightening” or “frightened”. (Liotti, 1999)
Disorganized Attachment
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In studies of abuse and neglected children,
disorganized attachment styles have been
found in over 80% of maltreated children
(Carlson et al, 1985; Ogawa, 1997)
Disorganized attachment is also statistically
significant predictor of dissociative symptoms
by age 19 and diagnoses of Borderline
Personality Disorder and Dissociative Identity
Disorder (Lyons –Ruth, 2001)
The Trauma Mechanism
Belief system
Behavioural
re-enactment
Other mental
health problems
(Co-morbidity)
e.g. Major Depressive
Disorder 48%
Trauma
Developmental
impact
(Mal)adaptive
coping strategies
Physiological
response
Behavioural Reenactment
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Young people can expose themselves,
seemingly compulsively, to situations
reminiscent of the original trauma.
In behavioural re-enactment of the trauma
the characters may play the role of :
victim/perpetrator/rescuer.
Three key ways: Harm to Others; Selfdestructiveness; Re-victimization.
Children seem more vulnerable than adults to
compulsive behavioural repetition and loss of
conscious memory of the trauma.
Key concepts
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Behaviour is seen as being related to either
Hyper-arousal or Hypo-arousal – related to
either attachment and / or trauma disorders
(Cross, 2005)
Based on sound neurological research about
the impact of trauma, attachment and
neglect,
The use of social milieu and the therapeutic
residential care staffs interactions with the
child can help regulate the child behaviour
(symptoms of trauma),
Key Concepts
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No child who has experienced trauma is
going to heal and learn to use different ways
of coping without first feeling secure,
For children who have experienced chronic
trauma, the importance of environmental
interventions can not be overemphasised and
is viewed as essential (Shirar, 1996, p 146),
in terms of providing the stable and safe
place from which therapeutic work can be
undertaken (milieu e.g. understanding of
parallel processes etc throughout
organisation).
Example of structures to help (must be done for all
elements of trauma mechanism - hyperarousal etc ):
Strategies for Traumatic Re-enactment
Children and Young people:
- Redirection of Traumatic Scenario
- Life Space Interview (provide opportunity to
develop insight)
- Safety Planning
- Trauma Work
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Staff & Program:
- Staff Training
- Debriefing
- Focus on Self Awareness
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Theory into Practise
Hyper-arousal (aggression, impulsive behaviour, children
viewed as high risk, emotional and behavioural problems
– ‘Fight or flight’ response)
Window
Of
Tolerance
Hypo-arousal (dissociation, depression, self harm etc)
If Child Is Experiencing High Arousal we
need to show Low Arousal – Common
sense that can be difficult in practise
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A non-confrontational way of managing
challenging behaviour
A philosophy of care which is based on
valuing people
An approach that specifically attempts to
avoid aversive interventions
An approach that requires staff to focus on
their own responses and behaviour and not
just locate the problem in the person with the
label
A collection of strategies that are designed to
rapidly reduce aggression
Theoretical
Assumptions
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ASSUMPTION ONE
Most people who are challenging are usually extremely hyperaroused at the time. We should therefore avoid doing anything
that will arouse a person who is already upset.
ASSUMPTION TWO
A large proportion of challenging behaviours are usually
preceded by demands and requests, therefore reducing these
should help to reduce the frequency and perhaps the intensity
of the incidents.
ASSUMPTION THREE
Most communication is predominantly non-verbal, therefore we
should be aware of the signals we communicate to people who
are upset.
One technique to take away: life space
interviews… using a technique to increase
coping and understanding
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The following is a brief overview of an approach
initially developed for work with high risk
adolescent but has been found to work well
with children…
Other approaches can be added to this to
increase outcomes which I developed as part of
a set of therapeutic techniques for working with
adolescents. I will be running in future
workshops on these in the future e.g. advanced
role play strategies.
Using Drawing – with high
risk adolescents
Simple is best,
 Let young person create own symbols,
 Remember safety must be in place first,
 Young person has developed self care
strategies,
 Remember, at times process might
need to return to stabilisation phase.
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What was happening around
me
What was I thinking
What was I feeling?
How it is all put together…
If I don’t hit him
first he will hit me!
He is laughing
at me.
Walking down street and
see ‘Joe… who I don’t like.
6/10
Conclusion:
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Link between trauma and attachment styles in
ability to regulate affect,
Importance of being able to help child learn
how to regulate affect,
Links between trauma and long term
consequences for not only the child but
society,
Proposal to utilise knowledge and
understanding relating to trauma and
attachment to create evidenced based
approaches to meet the needs of young people
for whom residential care has not address such
underlying needs (e.g. limited specialised
provision in Scotland)
The need total organisation approach to
therapeutic residential care
What we need to be aware of..
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Residential child care can replicate the toxic traumatic
experiences of children who are looked after e.g. multiple
placement breakdown,
Those responsible for identifying care for children need to
understand the high level of skill, support and resilience
required by the caregiver to ‘survive’ to enable improved
outcomes,
To be able to use the relationship the staff member has with
the child is crucial but to do so effectively, the individual needs
to be able to work within a therapeutic framework of
understanding which contains not only the work but which
directs and maintains an understanding of what we do and
how we do it for all those who work within the organisation.
Unfortunately to educate on such areas take time and groups
and teams can sometimes neglect such areas for short term
gain…. Above all it takes time to not only develop a culturally
sensitive environment to undertake trauma informed therapy
but also the development of an appropriately trained staff
group
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 different