Broken Bonds:

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(No Transcript)
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Working With High Risk Adolscents in Residential
Care Understanding the Links with Trauma
Richard Cross, CareVisions Group
http//www.carevisions.co.uk UKCP Registered
Psychotherapist Member Counselling Society
(Accredited) e-mail info_at_carevisions.co.uk

telephone [phone]
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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
• 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)

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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.

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Why Study Trauma?

• 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)

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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

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The truth?

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

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• All truth passes through three stages.
• First, it is ridiculed.
• Second, its violently opposed.
• Third, its accepted as self-evident.
• (Schopenhauer, 2006)

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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

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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.

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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

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Trauma Symptoms and Conduct Disorder

• Aggression
• Impulsivity
• Impaired empathy
• Anger
• Disregard for the future

• Substance abuse
• Risk-seeking behaviour
• Reactivity

Do you only see the behaviour?
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Trauma, attachment and Dissociation.

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

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

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• 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

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Grand Central The Brain

• 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)

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The Dyadic Dance

• The caregiver modulates the infants non-optimal
  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

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Modes of self-regulation

• Interactive regulation involves the ability to
  utilise relationships to mitigate breaches in the
  window of tolerance and to either stimulate or
  calm oneself,
• 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
• Ogden, 2002

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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 auto-regulate
  without the caregiver and is not self soothed by
  reunion.

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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

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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.
• Disorganized attachment status, on the other
  hand, interferes with the development of both
  auto- and interactive regulatory abilities
• Disorganized attachment in children is
  correlated with maternal behaviour which is
  characterised as frightening or frightened.
  (Liotti, 1999)

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Disorganized Attachment

• 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)

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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
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Behavioural Re-enactment

• 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
  Self-destructiveness Re-victimization.
• Children seem more vulnerable than adults to
  compulsive behavioural repetition and loss of
  conscious memory of the trauma.

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Key concepts

• 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),

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Key Concepts

• 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).

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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
• 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)

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If Child Is Experiencing High Arousal we need to
show Low Arousal Common sense that can be
difficult in practise

• 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

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Theoretical Assumptions

• ASSUMPTION ONE
• Most people who are challenging are usually
  extremely hyper-aroused 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.

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

• 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.

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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
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What was I thinking
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What was I feeling?
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How it is all put together
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He is laughing at me.
If I dont hit him first he will hit me!
Walking down street and see Joe who I dont
like.
6/10
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Conclusion

• 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

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What we need to be aware of..

• 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

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If we do nothing the Legacy?

• Increase in distress
• Higher Criminal Justice costs.
• We will be letting our children down
• We wont 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.

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• The Future can be different