Dr Ian Barron, University of Dundee
Scotland’s Secure Estate (ESS; Good Shepherd;
Kibble; St Mary’s)
David Mitchell, Rossie, Young People’s Trust
Dr Ricky Greenwald, Child Trauma Institute
Dr Bill Yule, Atle Dyregrov and Patrick Smith,
Children and War Foundation.
David Cotterell - A Scottish Government funded
project
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Shift focus - symptom management (attempting to control violence, anger and
drugs use) to healing the underlying trauma which
(i) drives the behaviour and
(ii) results in YP being unresponsive to behavioural programmes
Introduce trauma-specific screening and evaluation
(i) Develop a developmental trauma framework to case files analysis
(PTSD – DSM IV and developmental trauma lens – Bessel Van der Kolk)
(i) Trauma history interview (Dr Greenwald’s Treating Problem
Behaviour script)
(iii) Standardised measures (CRIES-13; MFQ; TGIC; ADES; SDQ).
Introduce and evaluate trauma-specific intervention
Training for trauma-sensitive milieu
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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’
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 “any
bang becomes a bomb” (Myers, 2009)
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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.
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Trauma invisible in medical files
Physical rather than mental health focus
Symptoms rather than diagnosis
No connection to embodied symptoms & YP
trauma
‘Scatter Gun’ of professional involvement
Wide range of ‘types’ of professions recorded per
YP
Up to 31 different types of professional – frequent
changes
Omission of survivor organization/expertise
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Multiple ‘types’ of harm/trauma: 10 different
types categorized: sexual 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
Despite extensive abuse only 1 YP
experienced justice through the Scottish
Legal system for harms done to them
(perpetrator imprisoned)
Vs.
• YP experienced multiple child protection
case conferences, children’s panels, review
meetings, supervision meetings, care plan
meetings, police stations, over-night
custody and charged with various and
numerous offences.
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Descriptive behaviours, e.g. hostility, self-harm,
drug taking etc. NOT set within trauma lens
Omission YP internal intrusive/sensory
experiences
Few PTSD assessments (n=3; TSSC) & no
diagnosis as YP “unpredictable” invalidating
result??
N=8 files recognised daily events as behavioural
triggers – not connected to historical abuse, e.g.
derogatory comments to young people, worries
about stability of mother’s residence
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Extensive behavioural difficulties
Multiple charges
Severely disrupted educational histories
Families relationships characterized by violent chaotic disorder;
Violent peer relationships
Lack of future hope frequent
Negative behaviours/emotions for all (Emotional dys-regulation)
Disturbed cognitions rarely reported
Re-victimisation statements common
Dissociation (n=2) - no evidence professionals making connection
between substance misuse/self-harm
Depression rarely named (n=3) - symptoms reported
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PTSD & developmental trauma symptoms pervasive with YP in secure care
Professional reports indicate lack of understanding of the impact of trauma on
YPs presenting behavioural difficulties
Post-placement decision-making equally characterized by omission of trauma
lens
No trauma-specific programmes
Substantial need across health and welfare services (whole system) working
with children, who have been neglected and abused, to understand:
(i)
the nature of children’s traumatic experience
(ii)
how to apply this understanding to placement decisions,
support and
trauma-specific interventions for YP
(iii)
take cognisance of this during exit planning.
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9 T events on average; multiple 10s
cumulative Ts not processing - see cases
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. 1st time);
secure accommodation
No harm conducting Trauma Histories –
psycho-education
Clinical levels (mostly clusters) of:
• PTSD (65%)
• Depression (65%)
• Dissociation (18%) found in nearly all young
people (files)
• Clinically significant levels of complicated
grief
• Underestimated trauma as measures
developed around ‘single’ events
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Safety first; “safe now”; good attachment
Stabilization – calming and dissociation
techniques - improved affect regulation
Core relationship factors – empathic, warm,
positive regard, 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”
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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 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!)
Group/individual-CBT ‘Teaching Recovery
Techniques’ (TRT)
• Children and War Foundation - Patrick Smith,
Bill Yule & Atle Dyregrov
• Psycho-education - Intrusion, Hyper-arousal
and Avoidance
• Delivered in pairs, three & fours
• 7-8 session (vs 5 session)
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YP (N=17)
Intervention / control
Presenters PSDO team (n=3) - deliver behavioural change
programmes
Trauma history interview
SUDs; standardized measures (CRIES-13; MFQ; ADES; TGIC;
SDQ)
2 weeks pre/post TRT
Programme fidelity – video analysis
Interviews YP; Staff focus group
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Large effect size - reducing SUDs
Small effect size - behavioural change
No statistical difference - standardized measures.
Control group made small gains = secure is containing & stabilizing
(emotionally) while there
YP mostly positive about TRT experience & identified specific helpful
aspects
Presenters (i) YP selection and grouping important (ii) liaison with
care/education staff to enable transfer of YP strategies (iii) further
gains after evaluation
Programme fidelity very high
Substantial financial and post-placement gains were achieved for
some young people.
Whole staff group evidenced substantial knowledge gains in traumasensitive environments
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Some harm inappropriate to disclosure within a group
TRT - assessment of need for in-depth individual T therapy
Short duration placement impeding group delivery
On site individual therapy provides immediate access to
treatment within short placements
Individual therapy recognized as standard of care for T
treatment (NICE)
Evidence suggests TPB phase model enables high levels of
engagement & can lead to lasting change, i.e. true healing and
transformation
TPB is manualised/replicable & developed/tested with secure
care populations
Cost saving - time limited behavioural stabilization to intensive
trauma focused treatment
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5 provision across the whole secure care estate in Scotland involved
By April 2015 - 14 TRT practitioners; 24 TPB practitioners
Increased time spent with individual therapy for YP (1st year 5-10% of workers
time was increased to 10-30% ; expecting similar increase this year
Therapy more intensive (YP tolerate longer sessions) - treatment 4-6 weeks YP
entry
High standard of supervision - monthly review videotaped sessions & expert
consultation with Dr Greenwald
Practitioner capacity to adhere to programme implementation fidelity
dramatically improved
All staff trained in TPB trauma-sensitive milieu – enhances communication
programme/care staff
Writing reports from T-informed lens (report template and exemplars)
Sustainability – trainer of trainers model: 6 accredited TPB ‘trainers’ (Child
Trauma Institute); and 10 TRT trainers; international TPB network
Increase quality & no. of professionally trained staff / outsourcing
Eliminate stakeholders requesting less promising interventions – psychoeducation
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Field trial
T measures into ‘standard evaluative practice’ for benchmarking
programmes, practitioners, provision and longitudinal evaluation
Standardized measures for assessing cumulative trauma - Children’s Report
of Post Traumatic Symptoms (CROPS): Parents Report of Post Traumatic
Symptoms (PROPS) and the Problem Behaviour Rating Scale
Behavioural tracking (before/during/after) - point/level behaviour systems,
incident reports, medical utilisation, school performance, time to discharge,
type of discharge to higher/lower level of care
Programme adherence through scripts and video
Qualitative measures – interviews with staff and young people
Placement trajectory costs
Thank
you
 i.g.z.barron@dundee.ac.uk