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Similar to Trauma Training 19 March Nottingham YOT
Similar to Trauma Training 19 March Nottingham YOT (20)
Trauma Training 19 March Nottingham YOT
- 1. Trauma and Young People Dr Michelle Carr Forensic Psychologist Primrose Service March 2015
- 2. Session Plan Introductions Feeling Safe Professional Fears and Anxieties Defining Trauma How Trauma can Affect Children Break Trauma and Gender Working Effectively with Trauma Tools Questions Close
- 4. 1. Professional Fears and Anxieties “A can of worms is a can of worms whether it is open or closed” Peter Bullimore 2014 Exercise: Myth or fact? Do you have any?
- 5. Danger
- 6. Definition: trau·ma (trôm, trou) n. pl. trau·mas or trau·ma·ta (-m-t) 1. A serious injury or shock to the body, from violence or an accident. 2. An emotional wound or shock that creates substantial, lasting damage to the psychological development of a person 3. An event or situation that causes great distress and disruption. 2. Defining Trauma
- 7. Types of Trauma Direct Trauma- Such as rape and abuse, which are identified as maliciously perpetuated violence. This not only includes being the victim of these acts but also forced to commit the act. Indirect Trauma- Produced through secondary effects such as pulling bodies from wreckages, witnessing homicide or watching ones mother being beaten Insidious Trauma- results from being devalued because of an individual characteristic intrinsic to ones identity for example regarding race, sexuality, gender or culture.
- 8. What's Worse? Abuse Neglect Someone is interested No one is interested
- 9. Prevalence of Abuse In a study conducted in 2000 in the UK found that 16% of girls and 7% of boys have been sexually assaulted before the age of 13. More than twice the number reported that they had been abused by somebody they knew (parents or carers, other relatives, or by other known people) than had been abused by a stranger or by someone that they had just met. (Cawson, Wattam, Brooker, & Kelly, 2000) These results indicate that it is much more likely that a child will be abused by somebody they know.
- 10. Prevalence of Abuse • In 2014 a larger follow up study was conducted and the results show: • 1 in 5 children have experienced severe maltreatment • Children abused by parents or carers are almost 3 times more likely to also witness family violence • 1 in 3 children sexually abused by an adult didn’t tell anyone at the time • All types of abuse and neglect are associated with poorer mental health NSPCC 2014
- 11. “Children are too young to understand what's going on” 3. How Trauma can Affect Young Children
- 14. "My heart was beating so fast I thought it was going to break." 8 year-old child 3. How Trauma can Affect School Age Children
- 15. 3. How Trauma can Affect Adolescents
- 16. • PTSD→ dissociation, auditory & visual hallucinations • Emotional state –depression, anxiety, anger • Affect regulation • Self view → low self esteem guilt, shame • Self-harm • Behaviour –sexualised, disruptive • Social interaction → Abusive relationships • Cognitive and Educational Progress • Psychiatric disorders (e.g. ADHD, autism) • Developmental Milestones →Growth, eating, sleep • Non-organic physical problems (including somatic symptomology, wetting and soiling) • Identity 3. How Trauma can Affect Children
- 17. • Their behaviour is dangerous, reckless or harmful. • They seem persistently depressed or anxious. • They start abusing substances or their use increases dramatically. • They won’t communicate about where they’re going, what they’re doing or how they’re feeling. • They don’t seem to be showing any signs of recovery. • The individual is behaving completely out of character.
- 20. • Dangerous, reckless or harmful behaviour to themselves or others. • Persistently depressed or anxious. • Abusing substances or their use increases dramatically. • Avoid communication about where they’re going, what they’re doing or how they’re feeling. • Behaving completely out of character. 4.Trauma and Gender
- 21. 4.Trauma and Gender Girls/ Young Women Internalize exposure to trauma/ danger Poor social development More likely to consider suicide Higher levels of psychological distress May be more keen to open up and talk about trauma and symptoms Boys/ Young Men Act out in an aggressive manner Poor social development Higher possibility of successfully committing suicide Higher likelihood of being seriously injured Higher likelihood of experiencing community violence
- 22. 5. Working Effectively 1. The severity of the experience, did the child feel as though their life or anyone else's life was in danger. 2. Ask Socratic questions about the subjective experience of the child and get more details to about the range of emotions, thoughts and reactions which the child experienced. Normalising the response is important.
- 23. 5. Working Effectively • Allow non-judgemental communication • Show genuine care, interest and support • Allow for flexibility following the event or the disclosure • Continue to remain consistent even if the YP is withdrawing or behaving unusually • Normalise their reaction to the trauma
- 24. 5. Working Effectively • Re-establish routines and roles • Providing reassurance and a sense of safety. • Resuming regular mealtimes and bedtimes, • Returning to school • Renewing friendships • Leisure activities • Playing in a safe environment
- 25. Processing
- 26. Experiences in Close Relationship The Relationship Questionnaire Parental Authority Questionnaire Dissociation Experiences Scale Transactional Analysis Narrative Exposure Therapy Compassion Focused Therapy DBT Trauma Focused CBT Eye Movement Desensitization Reprocessing TREM Get.gg (worksheets, workbooks, recording sheets) Formulation Get Self Help This Way Up NHS Choices Psychological Self Help 6. Tools
- 27. Form of Communication -TA 1. Rationality- sense of identity, morals, principles, values. Distinguish between emotion and thought 2. Formulating and implementing goals- need to be achievable, help to develop priorities 3. Equality in the relationship- 4. Proactive- dependent, can be given trust and be responsible. 5. Being open- feeling safe and confident enough to be honest and open. 6. Internally Powerful- Understand they have the ability to change the feelings or behaviour they do not like.
- 28. Predisposing factors (early experiences) Precipitating factors (life events) Schema formation Core Beliefs Assumptions Rules / beliefs Automatic thoughts Presenting problem Thoughts Physical Emotions feelings Behaviours Protective factors Perpetuating Factors (maintaining) Precipitating factors (triggers)
Editor's Notes
- Trauma is an extremely sensitive subject not confined to certain populations, individuals or just the people that we work with. It can happen to anyone and often does. It can occur in a variety of different ways and I just want to make it very clear that if anyone feels uncomfortable or experiences any negative emotions because of anything please do not hesitate to leave take a few minutes, talk to me, let someone know etc.
- Think about whether it is in fact your own personal fear or whether it is clinically justifiable to be avoiding the topic of trauma. Ask the questions Can the therapist become traumatised? Rarely however it can happen. Research suggests that more often than not you will experience warmth compassion and genuine empathy towards that person. Supervision is massively important- There are different forms of supervision and it is the restorative type which is most helpful. It allows the clinician to think about their feelings, transference, counter transference instead of a managerial caseload approach. As a clinician my standpoint is that it is a deep privilege for someone to share one of the darkest moments of their life with me- I will always thank them for speaking to me and check in with them after the admission to ensure they still feel safe and their distress is low.
- Before we discuss what is meant by a "traumatic experience" or "traumatic stress," let's think about how we recognize and deal with danger. Our minds, our brains, and our bodies are set up to make sure we make danger a priority. Things that are dangerous change over the course of childhood, adolescence, and adulthood. For very young children, swimming pools, electric outlets, poisons, and sharp objects are dangerous. ”stranger danger” For school-age children, walking to school, riding a bike in the street, or climbing to high places present new dangers. In adolescents, access to automobiles, guns, drugs, and time on their own, especially at night, are new dimensions to danger. Dangers change depending on where children live and on their families' circumstances. There are three things that happen when we are in a dangerous situation. First, we try to figure out what the danger is and how serious it is. Second, we have strong emotional and physical reactions. These reactions help us to take action, yet they can be very distressing to feel and difficult to handle. Third, we try to come up with what to do that can help us with the danger. We try to prevent it from happening, try to protect ourselves or other people against harm, or try to do something to keep it from getting worse. How we feel about a danger depends on both how serious we think it is and what we think can be done about it.
- In traumatic situations, we experience immediate threat to ourselves or to others, often followed by serious injury or harm. We feel terror, helplessness, or horror because of the extreme seriousness of what is happening and the failure of any way to protect against or reverse the harmful outcome. These powerful, distressing emotions go along with strong, even frightening physical reactions, such as rapid heartbeat, trembling, stomach dropping, and a sense of being in a dream
- The term complex trauma describes the problem of children's exposure to multiple or prolonged traumatic events and the impact of this exposure on their development. Typically, complex trauma exposure involves the simultaneous or sequential occurrence of child maltreatment—including psychological maltreatment, neglect, physical and sexual abuse, and domestic violence—that is chronic, begins in early childhood, and occurs within the primary caregiving system. Exposure to these initial traumatic experiences—and the resulting emotional dysregulation and the loss of safety, direction, and the ability to detect or respond to danger cues—often sets off a chain of events leading to subsequent or repeated trauma exposure in adolescence and adulthood.
- Early childhood trauma that occur to children aged 0-6. generally refers to the traumatic experiences that occur to children aged 0-6. These traumas can be the result of Intentional violence—such as child physical or sexual abuse, or domesticviolence Natural disaster, accidents, or war. Young children also may experience traumatic stress in response to painful medical procedures or the sudden loss of a parent/caregiver Child abuse is a culturally defined phenomenon. As Kempe (1978) wrote: "the rights of a child to be protected from parents unable to cope at a level assumed to be reasonable by the society in which they reside" (p.263, italics added). What is regarded as "reasonable" changes within and between societies? For example: In a country where a large proportion of the child population is afflicted by malnutrition, a parent's inability to provide sufficient food to their child would not be categorised as neglect on the parent's part. This is not a proven piece of research however I have often found that individuals who have committed the most grave heinous crimes are those that say they have experienced neglect and lack of love and affection from caregivers. This is not to say that they didn't have anything or went without toys, food etc it might be that they never received a hug and due to this they perceived themselves to be neglected. This again links to the previous slide in that it is personal experience that counts and not always the tick box criteria of a diagnosis or an event.
- If we think about these numbers the prevalence can be hypothesized to be much higher in forensic populations.
- Strong associations were found between maltreatment, sexual abuse, physical violence, and poorer emotional wellbeing, including self-harm and suicidal thoughts. Recognition and recording The most popular analogy used for child abuse is that of an iceberg, where only a portion of the whole is visible. Dividing the iceberg into layers you get: Layer 1: those children whose abuse is recorded in the criminal statistics of a country Layer 2: those children who are officially recorded as being in need of protection from abuse, e.g. children subject to a child protection plan in England Layer 3: those children who have been reported to child protection agencies by the general public, or other professionals such as teachers or doctors, but who have not been registered Layer 4: abused or neglected children who are recognised as such by relatives or neighbours, but are not reported to any professional agency Layer 5: those children who have not been recognised as abused or neglected by anyone, including the victims and perpetrator.
- Children begin to form memories just before the age of 2 although this differs slightly depending on culture. Age of first memories is very early however by around the age of 10 these early memories begin to be replaced. This differs by culture for example when comparing Chinese and western children, Chinese children began remembering about a year later than western children and this is thought to be because Chinese are not encouraged to talk about themselves but to talk about things in the context of their community and because children are more egocentric- the world is all about them- they do not store this info as it does not seem as important as info about themselves. Whereas western children are much more strongly encouraged to talk about themselves from a very early age and this encourages the formation of memories involving them and others. Chinese children develop greater ability to pay attention. Also children have been picture of former school mates and although they claimed not to remember them they were wired up to a machine to assess perspiration and results found that the children perspired more when they saw a picture of a former classmate which would indicate an unconscious memory of face recognition. Young Young children rely on a "protective shield" provided by adults and older siblings to judge the seriousness of danger and to ensure their safety and welfare. They often don't recognize a traumatic danger until it happens, for example, in a near drowning, attack by a dog, or accidental scalding. They can be the target of physical and sexual abuse by the very people they rely on for their own protection and safety. Young children can witness violence within the family or be left helpless after a parent or caretaker is injured, as might occur in a serious automobile accident. They have the most difficulty with their intense physical and emotional reactions. Childhood Trauma Young children experience both behavioral and physiological symptoms associated with trauma. Unlike older children, young children cannot express in words whether they feel afraid, overwhelmed, or helpless. However, their behaviors provide us with important clues about how they are affected. Young children who experience trauma are at particular risk because their rapidly developing brains are very vulnerable. Early childhood trauma has been associated with reduced size of parts of the brain which are responsible for many complex functions including memory, attention, perceptual awareness, thinking, language, and consciousness. These changes may affect IQ and the ability to regulate emotions, and the child may become more fearful and may not feel as safe or as protected.
- The "purpose" of human memory is to use past events to guide future actions. For example remembering the exact details of putting our socks on each morning with details about each sock, which foot we put our sock on first etc. We did need to learn this early in our lives but it has become so routine and normal practice that it has been converted to general knowledge which and each time we put our socks on this memory/ recollection is generalised and added to all the other times we have put socks on so that when someone hands us a sock we don't need to ask where do I put this. But also then our brains are not filled with thousands of memories of us putting our socks on each morning. Events which are not normal or routine and those that arouse high emotions are stored as specific memories which we can use and recall specifically later. Because many parts of the brain are required to store different types of memories ie smell memories and taste memories and sight memories memory recall is effectively a kind of collage or a jigsaw puzzle, involving different elements stored in seperate parts of the brain linked together by associations and neural pathways. FLIPCHART THE GRAPH HIPPOCAMPUS and the AMYGDALA. Increase in stress- Increase in arousal The hippocampus is a small seahorse shaped part of the brain (hippocampus is Greek for seahorse) that has a role in giving memories a “date stamp”. Information comes in – it is stored for a while – it s given a date stamp and then passed on to the right “department” for long term storage. As levels of arousal build up to modest levels the hippocampus gets better at its job. However when levels of arousal or stress get too high then the hippocampus starts to fail in its job of giving a date stamp to the memories it is processing. The amygdala is a small almond shaped part of the brain and works, in part, to process emotional and sensory memories. Unlike the hippocampus, as levels of arousal or stress increase then the amygdala just keeps on getting better and better at its job. Study 2014 of Coal Miners involved in a gas leak and had developed PTSD (n=14) with n=25 control group They found that the coal miners with PTSD had significantly decreased gray matter volume in the hippocampus in addition to a decrease in volume covariance between the hippocampus and amygdala compared to the control group. This decrease in volume may be associated with the dysfunctional emotional memory processing in PTSD patients that leads to symptoms like hyper-arousal or avoidance. This can be linked to the argument about the extreme differing presentations of children who are abused/ neglected – the child who “acts out” and presents as challenging to those around him/ her and the avoidant child who doesn't say anything and goes through the motions. Both are as risky as the other. Dr. Zhang’s work, these findings were published July 7, 2014 in PLOS ONE
- Following trauma individuals have been found to have less gray matter in certain areas of the prefrontal cortex that have been linked to depression, addiction and other mental health disorders, the study authors say.
- School Age Children More ability to judge the seriousness of a threat and to think about protective actions. They usually do not see themselves as able to counter a serious danger directly, but they imagine actions they wish they could take, like those of their comic strip heroes. So, in traumatic situations when there is violence against family members, they can feel like failures for not having done something helpful. They may also feel very ashamed or guilty. They may be without their parents when something traumatic happens, either on their own or with friends at school or in the neighborhood. Sexual molestation occurs at the highest rate among this age group. School-age children get scared of the speeding up of their emotions and physical reactions, adding new fears to the danger from outside Young children depend exclusively on parents/caregivers for survival and protection—both physical and emotional. When trauma also impacts the parent/caregiver, the relationship between that person and the child may be strongly affected. Without the support of a trusted parent/caregiver to help them regulate their strong emotions, children may experience overwhelming stress, with little ability to effectively communicate what they feel or need. They often develop symptoms that parents/caregivers don't understand and may display uncharacteristic behaviors that adults may not know how to appropriately respond to. A younger child realises they couldn’t survive without their parents, whereas a teenager is more aware of their ability to make it ‘on their own’.
- Adolescent With the help of their friends, adolescents begin a shift toward more actively judging and addressing dangers on their own. During traumatic situations, adolescents make decisions about whether and how to intervene, and about using violence to counter violence. They can feel guilty, sometimes thinking their actions made matters worse. Adolescents are learning to handle intense physical and emotional reactions in order to take action in the face of danger. They are also learning more about human motivation and intent and struggle over issues of irresponsibility, malevolence, and human accountability. Depending on the trauma they have experienced and their personality and temperament these factors will depend on what they learn about trauma and how they cope with trauma. For teenagers, friends and peer groups are very important. By comparing themselves with their friends, a teenager gets a sense of how ‘normal’ they are. Teenagers tend to seesaw between independence and insecurity after a distressing event. This sort of contradictory behaviour can be confusing to the teenager and to the parents trying to help them Adolescents may respond to their experience through dangerous re-enactment behaviour, that is, by reacting with too much "protective" aggression for a situation at hand. Their behaviour in response to reminders can go to either of two extremes: reckless behaviour that endangers themselves and others, or extreme avoidant behaviour that can derail their adolescent years. The avoidant life of an adolescent may go unnoticed. Adolescents can try to get rid of post-trauma emotions and physical responses through the use of alcohol and drugs. Their sleep disturbance can remain hidden in late night studying, television watching, and partying. It is a dangerous mix when adolescent thoughts of revenge are added to their usual feelings of invulnerability
- A child can be affected in a infinite number of ways and an integration of various emotions including denial, Anger, Paranoia, Shame, Shattered Sense of self, loss of identity, confusion, feeling damaged, upset, confused, lonely, hurt, in pain. These emotions will differ depending on the abuse experienced and the emotions which were triggered during the abuse. For example if a child is abused and during the abuse they feared for their life their emotions will be very different to the child who was groomed and associated the abuse with love and receiving pleasure. Traumatic Grief Coping with the death of an important person in one's life is especially difficult for children. If the person died under traumatic circumstances or if the death was particularly traumatic to the child, that child may have a traumatic grief reaction. There is no right or wrong way to grieve, no "appropriate" length of time to experience grief following the death of an important person. The grieving process varies from child to child and changes as the child grows older. Children's reactions to death depend upon the child's age, developmental level, previous life experiences, emotional health before the death, and family and social environment. Common expected responses include: Emotional reactions such as sadness, anger, guilt, insecurity Changes in behavior such as aggression, loss of appetite, sleep problems Interpersonal difficulties such as social isolation, clinging, irritability Changes in thinking, including constant thoughts about the person, preoccupation with death Altered perceptions including believing the deceased is still present, dreaming about the person Neglect Child neglect occurs when a parent or caregiver does not give a child the care he or she needs according to its age, even though that adult can afford to give that care or is offered help to give that care. Neglect can mean not giving food, clothing, and shelter. It can mean that a parent or caregiver is not providing a child with medical or mental health treatment or not giving prescribed medicines the child needs. Neglect can also mean neglecting the child's education. Keeping a child from school or from special education can be neglect. Neglect also includes exposing a child to dangerous environments. It can mean poor supervision for a child, including putting the child in the care of someone incapable of caring for children. It can also mean abandoning a child or expelling it from home. Neglect is the most common form of abuse reported to child welfare authorities
- Psychologist- trainee forensic psychologists, request a psychologist assessment and then you can request exactly what assessments you need eg trauma, bereavement, CAMHS Action for Children MIND info@mind.org.uk 0300 1230093 CRUSE Berevavement Care 0808 8081677 The Samaritans 08457 909090 jo@samaritans.org Victim Support 0845 3030900 Childline Survivors UK
- Thinking about buffers we think about early attachments- Depending on the age the abuse occurs it can severely affect attachment to care givers and others potentially for the rest of their life. You can be the change in a young persons life- which allows them to shift to a more secure form of attaching.
- Psychologist- trainee forensic psychologists, request a psychologist assessment and then you can request exactly what assessments you need eg trauma, bereavement, CAMHS Action for Children MIND info@mind.org.uk 0300 1230093 CRUSE Berevavement Care 0808 8081677 The Samaritans 08457 909090 jo@samaritans.org Victim Support 0845 3030900 Childline Survivors UK
- First, it is important to keep in mind the details of what a child went through. Consider a child who is trapped in a seat belt after a serious automobile accident, parent unconscious, and the car on fire; a child on a playground being shot at by someone with a semiautomatic rifle; a child injured and trapped during an earthquake; a child who witnesses a parent take a knife to the other parent and then is left to try to stop the bleeding before help arrives; a child who must endure repeated and increasingly violent abuse by a parent or caretaker; a child who sees a friend killed in a hit and run accident; or an adolescent who is gang-raped. In general, the more violence, the more life threat and injury, the more witnessing of grotesque injury and death, the more severe and, potentially long-lasting the posttraumatic stress responses. A single traumatic experience can contain many traumatic threats and losses, making the recovery more complicated. Second, the child's subjective experience of what happened also helps to explain the severity and duration of his or her posttraumatic stress reactions. It is important to understand how terrified, horrified, or helpless the child felt, including the degree to which the child feared being seriously hurt or killed or having loved ones hurt or killed. In addition, the experience of physical violation of the body or betrayal by a parent or caretaker can lead to more severe reactions. Heightened physical feelings or a sense of unreality at the time may also add to the severity and duration of post-trauma reactions. Feeling that something a child did or did not do made things worse can also increase the severity of reactions.
- Most people only stay in emergency mode for a short period of time or until the immediate threat has passed. However, being in emergency mode uses up vital energy supplies and this is why people often feel quite tired afterwards.The normal healing and recovery process involves your body coming down out of a state of heightened arousal. In other words, your internal alarms turn off, the high levels of energy subside, and your body re-sets itself to a normal state of balance and equilibrium. Typically, this should occur within about one month of the event
- Inform parents, family workers, teachers, staff at children homes etc. This will take time and a lot of patience and effort AND CONSISTENCY – CONSISTENT FLEXIBILITY
- Weighing up whether allowing the child to process this event for example by going to the police and being involved in a court case will give rise to further traumatic experiences. The potential of this will need to be discussed with the YP and their family.
- Questionnaires-not long give an indication of the individuals current attachment style Rep Grid Examples of TA. You asking the young person “Hi how are you today” young person response “why do you care?” Adult to Adult “ I really like this bag” Adult to Adult “It’s really expensive” underlying parent to child “You cant afford it” Ever got the sense someone is implying something- this is what Berne is talking about. In terms of trauma a person can shift to child mode and it can become easy for us to shift from adult mode to parent mode without realising. We might say the say thing we would have said as an adult however it is received very differently. Formulation Work closely with a therapist to construct a trauma formulation – formulation is a posh word for a narrative understanding.
- How to help an individual shift from child mode to adult mode. It is often very difficult to do this when an individual has been in institutional care. As the workers do not often interact in an adult to adult way even when the individual is a young adult.
- Through early experience we form beliefs about ourselves, others and the world Negative Automatic Thoughts Assumptions / Rules Core beliefs