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Resource: creating a trauma-informed environment

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Resource: creating a trauma-informed environment

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Towards Building a Trauma-Informed Environment

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Video: self regulating to regulate others

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Video: self regulating to regulate others

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Lily's story: Trauma-informed practice in response to young people affected by extra-familial risks and harms

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Lily's story: Trauma-informed practice in response to young people affected by extra-familial risks and harms

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Lily-A case study of Trauma informed Practice

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-- Created using Powtoon -- Free sign up at http://www.powtoon.com/ -- Create animated videos and animated presentations for free.  PowToon is a free tool that allows you to develop cool animated clips and animated presentations for your website, office meeting, sales pitch, nonprofit fundraiser, product launch, video resume, or anything else you could use an animated explainer video. PowToon's animation templates help you create animated presentations and animated explainer videos from scratch.  Anyone can produce awesome animations quickly with PowToon, without the cost or hassle other professional animation services require.

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Amazon list of trauma-informed practice and calm box resources 

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Amazon list of trauma-informed practice and calm box resources 

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Paccione-Dyszlewski, M. R. (2016). Trauma-informed schools: a must. The Brown University Child and Adolescent Behavior Letter, 32(7), 8–8. https://doi.org/10.1002/cbl.30139

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A brief introduction to Trauma Informed Practice-LANGHOFF 2024

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6 ways to heal trauma without medication | Bessel van der Kolk | Big Think

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10 minute video introducing trauma-informed practice

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10 minute video introducing trauma-informed practice

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Trauma-informed Practice | The Innovate Project

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We propose that services should use a ‘trauma-informed’ approach to improve outcomes across practice systems.

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Trauma-informed Practice

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Addressing race and trauma in the classroom

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Addressing race and trauma in the classroom

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The National Child Traumatic Stress Network

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Helps educators understand how they might address the interplay of race and trauma and its effects on students in the classroom. The guide outlines recommendations for educators and offers a list of supplemental resources. It should be implemented in accordance with individual school policies and procedures.

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Addressing Race and Trauma in the Classroom: A Resource for Educators

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Helps educators understand how they might address the interplay of race and trauma and its effects on students in the classroom. The guide outlines recommendations for educators and offers a list of supplemental resources. It should be implemented in accordance with individual school policies and procedures.

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Secondary trauma and compassion fatigue

2021-03-02 02:13:58

Social work is a challenging career, exposing many practitioners to trauma and distress on a regular basis. Exposure to another's trauma can cause secondary trauma, which is a risk for anyone working in the helping professions. The following article is an extract from the Community Care Inform guide, Secondary trauma and compassion fatigue. It provides information, advice and tips to help social workers, and their employers, to understand and manage the impact of secondary trauma.

Secondary trauma (also known as vicarious trauma or compassion fatigue) describes the sense of hurt that those who are close to a victim of trauma may feel. Secondary trauma occurs when a 'helper' is exposed to extreme events directly experienced by another and becomes overwhelmed by the exposure to trauma (Figley, 1995). People who work with trauma victims are at risk of internalising their trauma, called secondary traumatic stress.

Secondary trauma is not a sign of weakness. It is an occupational hazard for helping professionals, and organisations must acknowledge this impact on their staff.

Providing education, support, and a safe working environment will support staff to work more effectively, provide better support and services for service users, enabling more effective/positive outcomes and overall strengthening the organisation.
Risk factors
* Length of service: social workers who are new to the profession may not have developed effective means to deal with the trauma they are seeing or hearing at work. Conversely, very experienced social workers are at significant risk because of the accumulation of trauma.

* Avoidance: secondary trauma may be more problematic for people who tend to avoid problems or difficult feelings, blame others for their difficulties, or withdraw.

* Support: a poor social support network.

Dr Bruce Perry at the Child Trauma Academy notes the following additional risk factors for secondary trauma:

* Empathy

* Insufficient recovery time

* Unresolved personal trauma

* Isolation and systemic fragmentation

* Lack of systemic resources
The impact of secondary trauma
Social workers may also experience trauma first-hand (in the form of threats, assault, racist or homophobic attitudes and so on). When coupled with exposure to secondary trauma, these experiences can severely limit professional capacity and judgment, in addition to having a profound effect on the worker personally.

The impact on you as a person
Cognitive
* Diminished concentration

* Confusion

* Spaciness

* Loss of meaning

* Decreased self-esteem

* Preoccupation with trauma

* Trauma imagery

* Apathy

* Rigidity

* Disorientation

* Whirling thoughts

* Thoughts of self-harm or harm toward others

* Self-doubt

* Perfectionism

* Minimisation
Emotional
* Anxiety

* Powerlessness

* Guilt

* Survivor guilt

* Shutdown

* Numbness

* Fear

* Helplessness

* Sadness

* Depression

* Hypersensitivity

* Emotional roller coaster

* Overwhelmed

* Depleted
Behavioural
* Impatient

* Clingy

* Irritable

* Withdrawn

* Moody

* Regression

* Sleep disturbances

* Appetite changes

* Nightmares

* Hypervigilance

* Elevated startle response

* Use of negative coping (smoking, alcohol, drug misuse)

* Accident proneness

* Losing things

* Self-harm behaviours
Interpersonal
* Withdrawn

* Decreased interest in intimacy or sex

* Mistrust

* Isolation from friends

* Loneliness

* Impact on parenting (protectiveness, concern about aggression)

* Projection of anger or blame

* Intolerance
Physical
* Shock

* Sweating

* Rapid heartbeat

* Breathing difficulties

* Somatic reactions

* Aches and pains

* Dizziness

* Impaired immune system

The impact on you as a professional
Job performance
* Decrease in quality or quantity

* Low motivation

* Avoidance of tasks

* Increase in mistakes

* Setting perfectionist standards

* Obsession about detail
Morale
* Decrease in confidence

* Loss of interest

* Dissatisfaction

* Negative attitude

* Apathy

* Demoralisation

* Lack of appreciation

* Detachment

* Feelings of incompleteness
Interpersonal
* Withdrawal from colleagues

* Impatience

* Decrease in quality of relationships

* Poor communication

* Subsume own needs

* Staff conflicts
Behavioural
* Absenteeism

* Exhaustion

* Faulty judgment

* Irritability

* Tardiness

* Irresponsibility

* Overwork

* Frequent job changes
Impact on the organisation
Secondary trauma has an immense impact on organisations. Workers experiencing secondary trauma tend to have higher levels of absenteeism, including long-term sick leave for issues including depression and anxiety. Many social workers move to teams considered less stressful or may move out of social work completely, resulting in team and organisational instability, high-cost temporary staff and recruitment costs. These issues affect individual and team functioning, making it difficult for the organisation to provide a safe and effective service.
Impact on service users
A social worker experiencing secondary trauma may be less effective in their assessment, or in danger of making poor assessments and dangerous decisions, putting people at risk. Service users will feel the impact of late appointments, cancelled or forgotten visits, half-hearted attempts and practitioners who don't seem to care. Longer term, they feel the impact of high staff turnover, with a parade of professionals to whom they must repeat their story.

Reducing the impact of secondary trauma
Personal self-care
Good self-care will not prevent secondary trauma. However, it will enable the practitioner to be in a stronger mental and physical state to cope with their experiences.
Physical
* Get an adequate amount of sleep

* Eat regularly and healthily

* Exercise regularly

* Take time off

* Seek medical attention when needed

* Take holidays and minibreaks (where possible)

* Be aware of distractions becoming inappropriate coping strategies
Psychological
* Make time for self-reflection

* Engage in counselling or therapy

* Write in a journal

* Decrease stress in your life

* Listen to your thoughts, judgments, and beliefs

* Learn how to say no
Emotional
* Give yourself affirmations

* Identify comforting people, activities, and places and engage with them

* Allow yourself to express emotions

* Avoid self-denial
Professional
* Take a break during your work day

* Get to know your colleagues and develop supportive relationships

* Use supervision (and demand it)

* Set limits/boundaries with colleagues and clients

* Develop rituals at work that promote camaraderie and support

* Develop end of the day rituals that help you close your work day
Spiritual
* Reflect on things, people, ideas that are important to you

* Try not to be 'in charge' or the expert all the time

* Find a spiritual connection or community

* Pray or meditate

* Enjoy nature

* Contribute to causes you believe in
Team self-care
* A positive and supportive team is an effective safety net in a very difficult profession. The impact of having colleagues who know you and can 'read' where you are and provide support and encouragement cannot be underestimated.

* Celebrate! Celebrate success, birthdays, Fridays - anything that can bring a positive atmosphere to your team.

* Make effective use of team meetings - it's one chance for everyone to be together to learn something new, support each other, and come up with creative solutions.

* Socialise outside work (bear in mind some team members may find this a challenge).

* Develop team rituals that help develop team cohesion and support.

* Develop ideas that could have a positive impact on work (for example educate service users on a topic that may result in reduced referral rates; share your expertise in an area with your team).

* Create an environment which does not allow for gossip and cliques.

* Create a positive physical environment (either at home or in an office).
How organisations and managers can help reduce the impact of secondary trauma
* Provide effective support and supervision. Supervision must be case reflective but also allow time and a non-judgmental space for workers to share the impact their work has on them.

* Develop an organisational culture that is one of learning, not blame.

* Look for ways to build diversity and job enrichment into the work. Vary workers' caseloads, and provide opportunities to do non-casework, such as participating in panels, facilitating training, or mentoring.

* Develop a culture where it is okay to express feelings about the impact of the work and where self-care is encouraged.

* Provide critical debriefing after an especially traumatic incident.

Remember that it may not be the incident itself that causes the trauma for the practitioner, it may be an accumulation of traumatic events or the personal situation of that worker. Workers who were not directly involved may also feel the impact of the traumatic event in different ways.

* Educate and support staff and managers around secondary trauma and provide a safe space for discussion and support.

* Provide visible, approachable leadership.

* Promote a 'we're in this together' attitude, especially when things go wrong.

* Ensure social workers' emotional and physical safety are considered as a top priority and processes are in place to provide support, especially with regards to working from home.

* Provide adequate salaries and time off.

* Ensure your staff know where they can obtain extra support (such as occupational health, employee assistance programmes).

* Provide sufficient induction, professional training, and management supervision for staff to feel competent and supported in their jobs.

* Encourage communication and staff contributions.

* Develop mentoring or peer mentoring schemes.

* Provide information to help staff understand how and why decisions about resource allocations, deadlines, policies, and assignments are made - help them see 'the big picture'.
Increase your compassion satisfaction
Compassion satisfaction is the contentment one experiences from being a helper. Despite the challenges of social work, practitioners often say their career is extremely rewarding. Although social workers bear witness to pain and trauma, they also bear witness to resilience and healing and the potential for changed lives. It is those experiences that workers must keep in the forefront of their minds to help them remain passionate and protected in their work.

"Although social workers bear witness to pain and trauma, they also bear witness to resilience and healing and the potential for changed lives."

The way an individual thinks about their work can reduce the impact of compassion fatigue. The Huntington Institute refers to this as "working protectively". As part of working protectively, in professional reflection, social workers should consider:

1. Why do you do this work? Has the reason changed from when you started? Have you lost your motivation? Can you become reinspired in your current role?

2. What aspects of your work give you the most pleasure, satisfaction, or sense of achievement? Can you increase those areas?

3. Do you know what you are doing in your work and why? Do you see 'the big picture' and your role in it for service users, the organisation, and the larger community?

4. How do you measure success at work? Do you need to reconsider how you measure it? While you might have an ultimate vision of success, is it a realistic one? Reframing success into bite-sized chunks is more realistic, and provides more opportunity for success and celebration.

5. What aspects of your work can you control? Determine what things are within your power to change and be creative. Rethink how you can manage those things that cannot be changed.

6. What are the personal costs and rewards of doing this work? How can you increase the rewards? Are the personal costs too great?

UNISON SAYS

We know members may not be aware they are suffering secondary trauma, which is why this article is helpful in raising self-awareness. Employers have a clear responsibility to safeguard their employees' welfare at work and employees have a right to expect this from their employers. You should speak to your UNISON rep if you feel the prime responsibility is being placed on you to manage the impact of secondary trauma. As soon as your manager is aware of your stress, they have a responsibility to support you. It is important the issue is raised with your employer. In cases we take for members, often a pivotal factor is the question 'did you raise?', 'with whom?' and 'when?.'

For more information on this issue, and all references, please see our full guide by Lori Goosen on Community Care Inform.

Published by MAED. View All Articles.

This page can be found at https://digital.mydigitalpublication.co.uk/article/Secondary+trauma+and+compassion+fatigue/3941559/696969/article.html.

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2021-03-02 02:13:58 Social work is a challenging career, exposing many practitioners to trauma and distress on a regular basis. Exposure to another's trauma can cause secondary trauma, which is a risk for anyone working in the helping professions. The following article is an extract from the Community Care Inform guide, Secondary trauma and compassion fatigue .

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It's helpful for non-specialists to understand a bit more about trauma. Trauma can be defined as the experience and effects of overwhelming stress. Trauma overwhelms a person's ability to cope when faced with threat, or when they believe there is a serious threat confronting them.

Moral injury is defined as "the psychological distress which results from actions, or the lack of them, which violate someone's moral or ethical code". Unlike formal mental health conditions such as depression or PTSD, moral injury is not classified as a mental illness. However, those who develop moral injuries are likely to experience negative thoughts, often about themselves and others involved in the traumatic incidents which have triggered their distress. These can range from guilt and shame, through blame and disgust towards others, to fear and loss of self-confidence. Read more on moral distress in Health Education England - NHS Staff and Learners' Mental Wellbeing Commission Report (2019)

Trauma, and the distress it causes, is determined from the perception of threat rather than by the magnitude of the event/s. This means that it can arise from what may appear to the outside observer to be relatively minor triggers.
The role of perception reveals why contrasting experiences can be traumatic, and why some experiences may be traumatic for some people and not for others. Differences between people and context, such as a person's, prior experience/s, and the extent and duration of the stress affect a person's capacity to respond. So, too, do their resources, including their internal resources.
This point is very significant and underlines the importance of hearing accounts of trauma and moral injury in a non-judgemental way, respecting the staff member's experience and narrative. In addition, it relates to the complexity of some experiences of trauma which will require patient listening and a degree of skill in structuring conversations. To give two possible examples related to the current pandemic:

A black staff member who had suffered discrimination in their life before Covid-19, may be struggling to cope with their experience of working through the crisis - in other words, suffering trauma on top of trauma

A staff member required to "shield" a family member, therefore confined at home in self-isolation, may suffer acute guilt at not having "played their part".

Such experiences are already coming to light.

Remember, as managers and leaders we are often not privy to the experiences that our staff have been subject to in their personal and work lives to date. We are all at risk of trauma and moral distress. This does not make one person stronger/weaker than another.

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It's helpful for non-specialists to understand a bit more about trauma. Trauma can be defined as the experience and effects of overwhelming stress. Trauma overwhelms a person's ability to cope when faced with threat, or when they believe there is a serious threat confronting them.

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Podcast: Completing the stress response cycle

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Podcast: Completing the stress response cycle

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Brenè Brown: Hi everyone, I'm Brené Brown, and this is Unlocking Us. In this episode, we're talking to doctors Emily and Amelia Nagoski about their really powerful book, Burnout. And let me tell you something, burnout is, I know, I'm with you, it's... All of us are in it, I think right now, and it's no joke. We talk about what causes burnout, what it does to our bodies, and also how burnout, really an emotional exhaustion, comes down to the neurobiology of emotion. What happens to us when we get stuck in an emotion? Did you know that there's a beginning, middle, and end? And one of the things that causes burnout and emotional exhaustion the most is when we get stuck in that tunnel? We don't complete the whole cycle. This is just... This made so much sense to me. And I'm recording this intro probably... Barrett, what do you think? 10 days after? Two weeks after I've done the interview. I've put these strategies into practice in my life; it has made a difference. We're going to talk about the seven easy ways to work through and complete the stress cycle. And again, I've been doing it and has made...

BB: Wow, it's... I can't believe I didn't know this, and it's so tactical and helpful. And burnout is my middle name, sometimes. So, this is a conversation that you will not want to miss. Okay, let me tell you about our guests before we get started. So, Emily Nagoski, Dr. Emily Nagoski is a sex educator and author of The New York Times bestseller, Come as You Are: The Surprising New Science That Will Transform Your Sex Life. Best title ever, PS. Her job is to teach people to live with confidence and joy in their bodies. Amelia Nagoski, DMA, which stands for Doctorate of Musical Arts, is an Associate Professor and Coordinator of Music at Western New England University. Her job, as she describes it, which I love, is to run around waving her arms and making funny noises and generally doing whatever it takes to help singers get in touch with their internal experience. In that way, her work is very much like Emily's. Emily's master's degree is in counseling, Amelia's is in choral conducting. One day, they realized they both got graduate degrees in basically how to listen and feel feelings, which, they say, may say something about their childhood. They both live in New England with a variety of cats and dogs and spouses.

BB: Yes, they are twins. Yes, they are identical twins. And yes, one time they did pretend to be each other, and it did not go well. And as the older sister of twins, I can tell you that plan only works on TV shows. Alright, let's jump in. Burnout. Alright, let's just jump right in. The name of the book is Burnout. It graphically repeats itself, so I like to call the book Burnout, Burnout, Burnout, Burnout, Burnout: The Secret to Unlocking the Stress Cycle. Here's what I want to say to all my listeners. Do you know all the times where I've said things like, "Yeah, I was doing this interview and it was kind of weird because he turned it into a personal coaching session and I was like, 'We should get more specific'?" Well, forget all that shit right now. I need this work. I've got a million questions for you. So, let me start with this question before we dig in to my multiply tagged and highlighted book. What led you to writing a book on burnout?

Emily Nagoski: Yeah, it's a very specific story. I wrote a book about the science of women's sexuality called Come As You Are: The Surprising New Science That Will Transform Your Sex Life. It was a sex book. But because the best predictor of women's sexual well-being is, surprise, her overall well-being, there's a chapter about stress and emotion processing. And in the six months after that book came out, I traveled across the country, and I would give all these talks about the science of women's sexual pleasure, and I kept hearing from women after the talk, they'd come up to me and be like, "Yeah, all that sex stuff is great, Emily, thanks for that, but you know, the one chapter that changed everything for me was the one about stress and emotions." And I was surprised. I had worked really hard on the sex science part of it. So, I brought this story to Amelia.

Amelia Nagoski: Yeah, and I was not surprised at all, because I was a conductor, and I had been to a conservatory. And in musical training, you are specifically trained in how to feel feelings and process them and express them on stage, so I know that it's a learned skill. And I also know that when you learn that skill for stage, that doesn't necessarily translate into knowing how to do it in your real life, and I had to. And Emily is the one who got me started on learning how to do that. So I reminded her of that and said, "Yes, of course people... That changes their lives; it changed mine. It actually saved my life twice.

EN: Which, insert the long story about Amelia being in grad school and hospitalized twice with undiagnosable pain, they ultimately removed her appendix. She was in a doctoral program that I'm just going to brag because I know she won't, she is the only woman who has ever finished this program.

BB: Damn.

EN: That's how misogynist the field of classical music is. And so imagine your identical twin crying in a hospital gown and you're a professional health educator and you don't know what's wrong. So I started giving her books about stress management, [chuckle] because it's what I had, what I had with peer-reviewed research here. And she started reading it and she called me on the phone crying, like "This book says that feelings exist in your body. Is that true?" How could you not know that? How?

AN: Literally, I'm a conductor and my job is to express emotions with my body. But look, if I had recognized that emotions are in my body all the time, oh, that's a lot of emotion from my whole life that's in my body, and if I had been... If I have been recognizing that, that might have led to some suffering. Turns out, what I learned is that you need to turn toward that difficult stuff, and that actually it feels hard in the moment, but it, in the big picture, alleviates suffering.

EN: So we have this experience with her in grad school and she said, "Yeah, remember that time that it saved my life and... Okay, so we should write a book about that." And so that's how we got started. That was in October of 2015.

BB: I absolutely... I'm almost speechless, and y'all have to know that that's very rare for me, I study affect for a living. I have 400,000 pieces of data. And I'm understanding things about myself for the first time, reading your book.

EN: You don't know what's happening in my heart right now. So, here's the way I write; I write a chunk, I print it out, I walk around my house reading it out loud to a specific audience. And sometimes I'm thinking of a specific student who I had this conversation with. Sometimes I'm thinking of Beyoncé. And there were days when I was like, "Would this really make sense to Brené Brown? Like if she read this book, would she feel seen and understood? Would she feel like she was gaining insight?"

BB: The answer would be, "Oh hell yes." Like, "Yes." And I'm working on new research on emotion right now and I just... The way you write about... I don't know. It is a little bit of a love affair, I have to tell all of our community listening, because not only is this swirl of peer-reviewed research, amazing synthesis, music and pop culture TV references, it's like all good things are right in here. Let's start with Herbert Freudenberger. Okay, so Herbert Freudenberger in 1975 gave us a definition of burnout. Tell us about the three components.

AN: So the three components of burnout are emotional exhaustion, decreased sense of accomplishment and...

EN: Depersonalization.

AN: Depersonalization. I'm just going to lay this out here that I'm a COVID long hauler, and the brain fog is real. So sometimes I'm staring at things and I don't remember what I was doing. Okay, so there's...

EN: I'll pick it up when you fall away.

AN: When those happen... And that's why I have a sister to be the rest of my brain for me.

BB: Yes, sisters that pickup things. I'm so glad you're on this side of it, and I'm so sad that it's a long haul because I've got a couple of long hauler friends that it's just people do not understand what's involved.

AN: So those three things. Herbert Freudenberger with the decreased sense of accomplishment, emotional exhaustion and...

EN: Depersonalization.

BB: Okay, so emotional exhaustion, I think we... I love this definition that you put in here, which I guess is Freudenberger's: the fatigue that comes from caring too much for too long. Depersonalization: the depletion of empathy, caring and compassion, and then decreased sense of accomplishment: the unconquerable sense of futility, feeling that nothing you do makes any difference.

AN: Yeah. And in particular for women, it's the emotional exhaustion.

BB: Okay. So that's the thing that killed me. So, burnout, super high across everyone. I would imagine now in the time of COVID that burnout is at an all... Do we have any data that's telling us what's going on with burnout right now?

EN: Not to my knowledge specifically. Most of the research on burnout, it began about professional burnout and it stayed about professional burnout for a really long time. The ICD-10's definition is about professional burnout. It's only in the last five years or so that work on parental burnout has begun, though you can imagine exactly how this shows up for parents and caregivers of all kinds. And we know for sure from journalistic reporting that's been done that women are being laden with the lion's share of the adapting that has to be done when people are working from home, when people lose work, when schooling has to happen at home, whose job is all that stuff? Even in the countries where it is the most fair, and that includes the United States, it's still massively increasing women's workload and not men's.

BB: So we've got the unpaid second shift and the unpaid third and fourth shift now.

EN: Exactly.

AN: And COVID for sure, like a pandemic and all the other...

[vocalization]

AN: That's going on in the world are chronic stressors, and there's a lot of new writing about compassion fatigue, because people who aren't sick are always worried about the people around them getting sick and yeah, it's a perfect storm for burnout.

EN: And vicarious traumatization, I'm really worried about the caregivers and the medical providers who've been exposed to just emergency rooms and ICUs packed with people, and witnessing death on a scale that is just not something we've seen in the United States ever before.

BB: Yeah, I agree. So when I read people helping people, just high, high rates of burnout, and you write here, "In the 40 years since the original formulation, research has found that it's the first element in burnout, emotional exhaustion, that's most strongly linked to negative impacts on our health, on relationships, and work, especially for women." So then you take us into a primer on emotion. I think it'd be helpful for folks here to... What is emotion?

AN: This is the part of the book that 20-year-old me needed to hear, because when I was 20-ish, I was not convinced 100% that emotions were like a real thing. I sort of had this image of emotions is like an airy-fairy somewhere out there feeling...

BB: Very gauzy and... Yes.

AN: Yeah. And I needed science in my mid-30s to prove to me that emotions were real, even though I was literally a professional musician and expressing emotion was my job. I guess the performance aspect of it made me able to separate myself. Okay, emotions are cycles that happen in your body. They are neurological events, and when I say neurological, I mean not just happening in your brain but your whole nervous system, the intelligence of your body extends to your nervous system from the top of your head to the tip of your toes and also beyond your skin. Emotions are an involuntary neurological response. They have a beginning, a middle and an end.

BB: I just found that so helpful.

EN: The metaphorical version is feelings are tunnels, you have to go all the way through them to get to the light at the end.

BB: I have that double-highlighted here. I have a couple of things. "Just about every system in your body responds to the chemical and electrical cascade activated by emotion. Emotion is automatic, instantaneous, it happens everywhere and it affects everything." It's so funny to me in my work, how much time I spend trying to help people understand, people really want to believe, and myself included, and I think my 20-year-old would have liked your 20-year-old, that we are cognitive rational beings who on occasion feel, when the truth is, and we know this now from PET imaging for the last decade, we are emotional beings who on occasion think. So, I'm going to quote this from the book. I just want everyone to take a deep breath, like everyone... Lots of walkers and runners listen to the podcast and a lot of people driving. So, pull over, you might have a moment here, or just step up on a curb. "In short, emotions are tunnels. If you go all the way through them, you get to the light at the end. Exhaustion happens when we get stuck in an emotion." What the hey-ho?

AN: I know, right?

BB: Okay, I've got to keep... Can I keep reading here for just a second? Can I read y'all to you? "We may get stuck simply because we're constantly being exposed to situations that activate emotion: our crush is here, and all day every day, if only in our thoughts, and so we're trapped in our own longing for our crush. Or we return to a stressful job every single day, which is no wonder the helping professions are so exhausting, you're connected with people in need all day, day after day. Sometimes we get stuck because we can't find our way through. The most difficult feelings, rage, grief, despair, helplessness," I would probably maybe add shame to that, "may be too treacherous to move through alone, we get lost," I love this, "and need someone else, a loving presence to help us find our way through. Many of us are trapped in this way because of a problem we call Human Giver Syndrome." So, I want to go back to this, "Exhaustion happens when we get stuck in an emotion." Oh my God.

EN: Emotions have a beginning, a middle, and an end. A lot of us are taught to believe that if we fix the problem that caused the stress or the emotion, then we will have dealt with the emotion itself. It turns out, no, there is a disconnect in the world we live in now between the behaviors that deal with the things in our lives, like the crush across the room. There are things we can do to deal with that, and almost none of those things, like when you bravely go up and you're like, "Hi, here's my name. How are you?" And then you leave the room, and do you suddenly feel like peaceful, relaxed, "I dealt with the situation, I feel like I took a step forward"? No, you have to go scream in silence in the bathroom and call your friends because you still have to deal with the feeling, which is a separate step from dealing with the issue that was activating the emotion in your body. Most of us are taught to believe other people's opinions about our bodies more than we believe what our bodies themselves are trying to say to us. And so we believe when we are told that, "Well, I mean, you dealt with the issue, so you should be done feeling by now."

EN: "So why do you still have all these feelings? We don't want to hear about your feelings anymore. Your feeling should be done because the situation is done, so let it go, we are so tired of hearing about you and your feelings." And you're like, "I must behave myself emotionally so that I do not interfere with anyone else's well-being, and so I am now officially done with my feelings." And you smile and you shove it down into some organ system, I don't know which one, and then it lives inside you.

BB: And it metastasizes, right?

EN: Oh yeah.

AN: It's not necessarily the worst choice you can make in that moment. In some moments, smiling and being polite and walking away and containing and shoving it all down and hiding it can make you safer. You don't want to confront every douchebag on the side of the road who yells, "Hey baby, nice tits." That would not be safe. So you squash it down and you hide it, and then you get home and you're like, "I'm such a strong badass, I just ignored that guy." No. I mean, yes, but now finish that feeling, go back and revisit it and go through the whole cycle.

EN: Complete... Get the rest of the way through the tunnel.

BB: Get through the tunnel, okay. Okay, before we start talking about this piece around separating stressors and stress, let's talk about what Human Giver Syndrome is. Damn this syndrome.

AN: Human Giver Syndrome... Yeah, absolutely. It's a phrase we adapted from a book by a moral philosopher named Kate Manne. The book is called Down Girl: The Logic of Misogyny, and it's an intense dark read of moral philosophy, but it's short and readable. I highly recommend it, it's fantastic. But she does lay out in that book a moral system where a world contains two kinds of beings: human beings whose job it is to live, to express, to be their humanity, and they have a moral obligation to acquire whatever resources it takes in order to accomplish their moral obligation. And on the other hand, the human givers whose moral obligation it is to give their humanity, their time, their lives, their bodies, their feelings to the human beings. Guess which one the women are. This is a cartoon version.

BB: Yeah, I'm like, "No, ma'am. No, ma'am." Yes, this is terrible.

AN: Emily and I are both married to men who are givers. They turn towards our needs with kindness and compassion, they do not feel entitled. So absolutely there are men in the world who do not feel this way. In the large scale though, a lot of us have Human Giver Syndrome, men and women alike, where we honestly do believe that it is the moral obligation of women to be at all times pretty, happy, calm, generous, and attentive to the needs of others. And if we at any time fail in our moral obligation to be pretty, happy, calm, generous, attentive to the needs of others, then we deserve to be punished. And if there's no one around to punish us, we will just go ahead and punish ourselves.

EN: And that includes if you're married like we are, to fellow givers who are not going to punish us for falling short of it. But as people with Human Giver Syndrome, if our partners won't beat us up, we'll just go ahead and start whipping ourselves for the ways that we fell short of being able to save humanity and everyone in the world.

BB: Yeah, so this is part of, I'm thinking about this in kind of gender non-conforming terms. I think this idea, when I was reading it, the Human Giver Syndrome, anyone who finds themselves wanting to be aligned with feminine cultural norms, this is a part of that syndrome. It goes back to the research that I found probably, I don't know, maybe six or seven years ago, where it still said cultural norms for femininity in the US are still nice, quiet, and spending all resources on appearance. It's really just, "stay quiet and small and just take care of other people" basically.

EN: Yeah. And Kate Manne is clear that this is an intersectional issue, so for people of color, they're expected to be human givers to anyone who is white. And one of the grotesque ways that this plays out is that white women, feeling so trapped by human giver syndrome take on the role of human being and feeling entitled to take anything they want to from people of color, from people with disabilities, from immigrants, from poor people. In her new book, Entitled, Kate Manne uses the language of leaning down instead of leaning in. White affluent women lean down on immigrant and Brown and Black women in America. So one of the most important things we can do is recognize it for what it is and heal the damage that it is doing to us so that we don't take that damage out on anybody else.

BB: So we don't lean down.

EN: Right.

BB: Okay. So, what we understand so far...

EN: We're still in the introduction, by the way.

BB: Yeah, no, we're still on the introduction, but I just want to... I want to lay this out because the way the book is laid out, I have to say as a writer, is really smart, and it really walks people through this. So, we know that emotions are real, they're science, they're neurobiology, they're in our body, they affect everything we do all the time. We know that they have a beginning, middle, and end. And we know that we have to move all the way through them in order to... What happens when we get stuck in the middle of the emotion tunnel? What is the outcome of that?

EN: You end up in the hospital like Amelia. And the reason that happened, so if we take stress as the exemplar emotion, you think about all the things that... Let's take just the example of the cardiovascular system which we do in chapter 1, your blood vessels are designed to tolerate like a steady sort of pulsing stream of blood flow. And when your adrenal level goes up your blood pressure goes up and it's like a fire hose spraying in your blood vessels. And your system is competent at dealing with that when it lasts as long as it's supposed to in the environment where we evolved, which means it's going to last maybe 10 minutes and then be over.

EN: But we stay in this state of chronically elevated stress for hours, days, weeks, months, years at a time, and this causes wear and tear on our blood vessels, which causes weak places for plaques to develop, and this is how stress causes heart disease, and that's just one of the systems. Take your endocrine system as another one, your digestive system. Your digestive system is one of my favorites because it is so common for stress to show up in people's digestive systems. Complicated, fascinating things happen where your upper digestive system slows down, but your lower digestive system tract speeds up, and then you get IBS.

BB: God. It just totally makes sense. Okay. So let's start with the chapter on Complete the Cycle. I just need everyone to get it and read it. Well, it really is... I'm not like a journalist where I just, any book that comes out I have to talk to the people. I'm a podcaster, I just get to talk about books that make a difference, and so this is one of them. Tell me, define, and differentiate stress and stressors for me.

EN: So your stressors are the things that activate the stress response, they are... Most of them are external, so this is like work, kids, money, white/cis/hetero patriarchal, rapidly exploitative, like capitalism, small things that activate the stress response. Some of them are internal things like body self-criticism and trauma history, and they activate the stress response. The stress itself is what happens in your body, it's this chemical stew that gets activated in response to it, and it's designed to help us evolutionarily survive the stress like being chased by a lion or charged by a hippo. Amelia's favorite animal is hippo so I always make sure to say that hippos are the most dangerous land mammals on earth except for humans, so you could be trampled by a hippo. And when you're being chased by a hippo, what do you do?

BB: I run.

EN: Yeah, you totally run. Absolutely. And imagine you managed to run away from the hippo because hippos actually don't have a lot of stamina, so you run all the way, and somebody waves you into through their door and you close it and you shut it and the hippo gives up, and it's like, "Never mind," and just runs away. And you look at this person who just saved your life and you feel this rush or just exhaustion but this joy to be alive, and it seems like the sun is shining brighter and you love your friends and family, and you're so grateful to be alive. It's easy to think that it is the hippo going away that made that happen, but it's not, it's the running and the connection. Your body only knows what those behaviors are. Those behaviors are what say to your body, "You have escaped from this stressful situation and your body is now a safe place for you to be." It is the behavior, it's not the change in your environment that triggers the physiological change.

BB: So here's where I think we need to go into slow motion, and walk people through this. Removing the stressors does not mean the stress cycle is complete.

AN: Yeah. It means two things. It means that you don't have to wait for all the stressors to go away before you can start to feel better, but it also means that when the stressors do go away, it means you have to deal with the stress itself separately. I want to tell a story about when we were... When the book was first released in the United Kingdom and Ireland, we talked with a journalist in Ireland who had been part of the movement to legalize abortion in Ireland. And it had just recently passed, and she was telling us that she read this part of the book and she thought, this explains a lot because they had invested so much in their activism and going door-to-door and working so hard. And the good thing happened, the stressor went away, they were all done and they thought they would feel amazing, but no, they all collapsed, they all got sick, they all felt terrible. Even though this terrific news had happened, they felt bad, and it was because all the stress of that work, even though the stressor was gone, they hadn't dealt with the stress in their bodies.

BB: So this is so interesting, because I mentor a lot of women, MSW students, Master's in Social Work students who are getting PhDs. And so, I always warn the doctoral students that when you turn your dissertation in, and you're really done with your re-writes and everything, you're going to hit a wall and it's going to be painful, and they're like, "No, I'm not hitting a wall, I'm going to the Caymans." And you know what? They all get sick. And so, okay I want to read this, geez, in the book we're on page seven you all. "You have to do something that signals to your body that you are safe, or else you'll stay in that state with neuro chemicals and hormones degrading, but never shifting into relaxation. Your digestive system, immune system, cardiovascular system, musculoskeletal system and reproductive system never get the signal that they're safe."

AN: Because your body speaks body language, your body doesn't know that filing your taxes mean that you've accomplished something, your body doesn't know that a change of legislation means that you now have autonomy over your body's choices. You need to speak body language and fulfill the thing that it's intended to fulfill.

BB: People do not get that we cannot separate the body from affect emotion, it's why we call it feelings, right?

EN: Right. Exactly, exactly. And it's actually with the... Especially when it comes to illness and stress there's an extra layer of complexity. Your central nervous system only has a limited amount of bandwidth. If you're super stressed, there's a lot of noise in the highway of your brain and spine, and your immune system communicates with you through your nervous system via symptoms. So, if your symptoms are like, "Hey, you have a headache, hey, you're exhausted," your brain is like, "What? I can't hear you over the noise of all this exhaustion and stress. Are you trying to tell me something? What? Let me finish this project and then I'll listen to you." So you're sick all along, you hand in your dissertation, you're walking home, this is not a personal story at all, you're walking home from having turned in your dissertation, and you're like, "Oh, I'm really feeling not well," and you get, you have a fever by the time you get home and congestion headache by the time you lay down, and then you spend the next two days in bed, but you were... It's not because you all of a sudden got sick, you were sick all along, but now your immune system can finally get its voice heard over the noise of all the stress.

BB: "The stress itself will kill you faster than the stressor will, unless you do something to complete the stress response cycle. While you're managing the day's stressor, your body is managing the day's stress, and it's also absolutely essential to your well-being, the way sleeping and eating are essential, that you give your body the resources it needs to complete the stress response cycle that has been activated." Okay. So, why we get stuck? Number one, tell me about chronic stressor, chronic stress.

EN: This is the straightforward, like you're working on a big work project and you work on it really hard and you know you've got to complete the stress response cycle that was activated by this big project at the end of the day, so you get home and you do whatever the thing is. Do you have a thing that you know completes your stress response cycle, like when you do it, you're going to feel better, Brené?

BB: Yes, walking.

EN: Yeah, so you do your walk and you're like, "Oh, I feel so much better," and you hang out with your family and you eat something great, and then you get a good night's sleep and you wake up in the morning, and there's the big project for you to work on again. And so, you have to do the same thing to drain off the stress again. And if your stress level outpaces the resources you have available to drain off the stress, it will keep accumulating.

BB: I'm just going take a deep breath here. Okay, number two, the second reason we get stuck: social appropriateness.

AN: Yeah, yeah. The expectations, in particular for women, are that we never show anger, never express any intense emotions at all. Remember, we have to be pretty, happy, and yet calm, generous, and attentive to the needs of others. So in order to be safe in the world, in order to meet people's expectations, in order to not get fired from our jobs, we have to smile and be nice to the asshole. And the smart, safe thing to do in those moments is to bury that shit down and save it for when you get home.

BB: And then take it out on your husband, is that...

AN: Hopefully not, hopefully you go for a walk and eat something delicious and hug your family and, yes, but that is what would happen unless you deal with it separately.

BB: So number three is kind of tied to number two in some ways, so social appropriate. So the reasons we get stuck, one, chronic stress, two, social appropriateness, and three, safety. And this is the guy that's yelling, yelling at you from the street, and you just can't turn and confront that.

AN: "Hey, baby, why don't you smile?" And you want to punch that guy in the face, but would punching him in the face actually make you safer? Probably not, it'll probably escalate the situation. So the safe choice is to hang on to that for a minute 'til you get someplace safe and then deal with the stressor. Deal with the stress on its own separately.

BB: Okay. I want you to... And I realize I'm acknowledging going into this, we're going to get through the first three chapters of this book, but I think this is enough to change your life and then you can get the book. I want you to walk us through fight, flight, and then parasympathetically freeze. Can you tell us about that and how that relates to all of this?

EN: So, fight and flight are the things we're used to hearing about when we were in high school, we learned from Mr. Twilley, our science teacher, about the fight or flight response, which is the sympathetic "go" action. In less than a second your brain assesses a potential threat as something that you're most likely to survive by running away, in which case you get the flight emotions. So this is everything from worry, to anxiety, to fear, to terror, all the different fears, depending on the intensity of what's happening. And these are the avoid responses. So, it motivates you to be active and running away. And then sometimes in that split-second assessment it'll think, "This is a threat you can survive best by fighting." And this is an approach motivation, that's like everything from irritation and annoyance up through frustration and anger, and ultimately rage that pushes you to move toward the threat so that you can destroy it.

EN: And these are both, so they're action-oriented, either move away or move toward in order to deal with the stressor. And then under life threats circumstances, so your brain assesses the threat and it's like, "Nope, you are too slow to run, you are too weak to fight. Your best chance of survival here is to slam on the brakes in the middle of all this and play dead." So when you see this in the wild, the gazelle is running away from the lion, the lion's teeth chomp into the hip of the gazelle. And what does the gazelle do? It can't keep running, the lion has its teeth in her, so she flops to the ground. The lion feels all smug and wanders away to go get her cubs to feed on the gazelle, and this is when the glorious thing happens, so the gas pedal, the sympathetic nervous system has been pressed down hard and right in the middle of that big gas pedal stress response, bam, the brake slams on, everything shuts down.

EN: When the threat goes away, that brake begins gently to come off, and when you're watching the gazelle lying there, it will start to shudder, and its paws will shake in the air, its hooves will shake. And what's happening is, all the motor patterns that were activated but got interrupted as the brake comes off, they're completing their cycle, they're moving through what was already activated in the central nervous system, and it's just finishing out what was already there, so it purges. And then the gazelle stands up and it shakes itself off and goes, and it trots away, that's when the threat goes away and the brake can unlock, and the animal moves through the rest of it. And this happens for humans often in the case of trauma. One of the best examples of it, there's a brilliant book called, In An Unspoken Voice by Peter Levine, who is the originator of somatic experiencing.

BB: Yeah.

EN: He tells the story of being hit by a car, he's a pedestrian on the road, he's hit by a car, and he very vividly recounts the experience of feeling the parasympathetic brake. Sympathetic means with emotion, parasympathetic means beyond emotion. So everything shuts down, this is a life threat situation, he lies there, and as he's in the ambulance, he notices that he can feel the brake unlocking because he does this for a living, and he lets his shoulders shrug up and he lets his hands push flat out, and these are these small movements of allowing his body to release the thing that it needs to do. A lot of people who have surgery, when they come out from under anesthesia, which is medically induced freeze, will shiver and shake and they feel like they're cold, and they might be cold, but a lot of it is that shivering is part of their brake releasing and allowing them to shift back up into a healthy state.

AN: All of that is fine and good, and it works in gazelles and it works in human beings too, but there is a barrier that gets in our way. We all know about fight and flight. Most of us even know about freeze.

EN: Anybody who reads the book does, yes.

AN: Yeah. But the problem is that there's a kind of a hierarchy, a social ranking system, where we think that fight is better, and if you can't fight, well, at least you could flee, and if you freeze that means that you're weak and you fail. They're all morally neutral, they're all things that happen because your nervous system, in its wisdom, made a decision. And it's not that when you freeze, you're weak or you failed. When you freeze your body saved you, freeze is just as heroic as fight or flight. And the shame that's associated with flight and especially freeze is a thing that stops people from recovering from trauma because they don't allow themselves to feel a thing because they're ashamed.

BB: It's really interesting. I think that's true because shame often hijacks that same system, and the shame often can move us into flight, fight or freeze. And then people will always say, "Yeah, I'd rather respond to shame with shame, I'd rather respond to aggression with aggression, I'd rather walk away, but when I do that whole like bunny in the headlight thing, and I can't think of anything to say until later because my brain shuts down, that's just weak." So there is that hierarchical sense of the tough folks fight, then they run, but only the weak people freeze. It's the deer in the headlight kind of thing, when... This is, our body knows best what to do in these circumstances, it's just... It's hard. And then can you get stuck in that?

EN: It's always better to respond as if we're a predator. If we do something that a prey animal would do, then that's not ok, no. This by the way is how we wrote the book, is I would be like, "Here's the thing that happens in your body," and Amelia would be like... "And then there's all these cultural barriers to us actually using this information, so let's make sure we talk about the barriers so that people can get around them."

AN: Which goes back to that original question, which is, Emily was like, "How do you not know this?" And I'm like, "Nobody knows this." And there's really good reasons society is telling us that this information is forbidden and that we're not allowed to look at it and that if we do, then we're unveiling something dangerous, which is that we're human beings. And what we tried to do in the book and the thing that I learned most from writing the book is, the real answer is turning toward the difficult feelings with kindness and compassion. So whether you fight or flee or freeze, and if you have feelings about which one your nervous system chose to do, that's all fine. Turn toward that with kindness and compassion and let yourself finish the feelings and complete the cycle.

BB: So let's talk about that. And I love that, I love that... As a social worker, that's my training. So it's psychological, it's sociological, it's cultural, it's biological, it's systems of oppression. So to me, the context around everything you do is what makes the book so good. Let's talk about the most efficient ways to complete our cycles.

EN: Most efficient - physical activity.

BB: What kind of physical activity?

EN: Literally any movement of your body. For me, it's walking these days. When I was younger, it was running and long-distance cycling. It has also been rock climbing, I am a natural athlete, I absolutely have had the runner's high experience. Even on the days when I don't feel like it, I look at my shoes, I just don't want to. I know that if I just put on my shoes and I go, by the time I get back, I'm going to feel so much better. Amelia thought I was making it up when I said that. She's never had that experience. So it can be any form of physical activity. It can be dancing it out in your living room. It can be just standing up from your desk, tensing every muscle really hard, every muscle in your body until they're shaking and begging for you to stop and then you go...

[vocalization]

EN: And you flop down, put your hands on the ground and let your body soak and release. And that, even by itself, is going to begin to release the physical chemical stuff that was happening in your body with the stress. Any movement of your body.

BB: Alright, so number one is physical activity. Number two, breathing. Let's talk about breathing.

AN: Breathing down-regulates your nervous system, especially when you can take a slow breath in and especially a slow, long breath out. All the way to the ends of your abdominal muscles contract. That's how you know you're engaging the parasympathetic nervous system to down regulate the central nervous system. It is the gentlest way in to completing the stress response cycle, so if you're a person who has survived trauma, neglect, abuse, you have a significant history of adverse childhood experiences, a great place to start so that you don't get overwhelmed, is just with tuning into your breath, like a minute and a half worth of like breathing in and letting your breath go out.

AN: And your thoughts are going to go all over the place while you are doing this. That is normal. That is the point. You notice that your thoughts went all over the place, and you return your attention to the breath coming into your body and the breath leaving your body. When you don't have time to do anything else, it can also just siphon off the very worst of it, so that you're well enough to continue through the situation.

EN: Yes, if all you do is breathe and you don't attend to your thoughts, you don't do the mindfulness aspect, if you just physically breathe, that is highly evidence-based strategy for completing the stress response cycle, for down-regulating the nervous system. It doesn't have to be any work at all, it doesn't have to be any effort, you just breathe.

BB: I just... It's so hard because not only am I a super stressed out person, I'm a breath holder.

EN: Yeah, you are not alone.

BB: Yeah. So this is really helpful. We really underestimate the power of breath, don't we?

EN: Yes, yes, yes. Even when I first started learning the stuff, like everything, I underestimated how powerful it was, it sounded too easy, it sounded like it was kind of just like a hippie, made up thing.

BB: Totally.

EN: No. It's absolutely, it's how your biology works, it's how your body functions.

BB: It's just so funny too, because I write about breath in one of the most recent books, because I was really studying it around how to regulate and identify emotion. And the people who teach it the most, there's just two camps that I learned, yoga instructors do a lot of breath work, and special forces military.

AN: Really?

BB: Yes, it's probably I'm sure about completing the stress cycle, but it's also about being able to focus and recognize fear and emotion, so really interesting to me. Okay, so we got physical activity, breathing. Number three, positive social interaction, how do we complete the stress cycle there?

EN: The part of the story where the hippo is chasing you and somebody lets you into their place and the hippo gets held back because somebody welcomed you in and the first thing you do when you feel safe is you jump up and down and hug each other and high five and fist bump, that natural inclination to connect with other people tells your body that it is somewhere safe. Even if you are not physically in a place that is your actual home, your body can get the feeling of home because it's with someone who is your home. And that can be lightweight, it can be a positive social interaction with your barista. "Hey, I like your earrings." You know, just that much, tells your body the world is a safe place.

BB: Okay, I love the next one. Laughter.

AN: Yeah, the caveat with this is it can't be... Most laughter is social, posed laughter, it serves a function of lubricating conversations and making everybody... It can't be that fake laughter. It has to be the slightly embarrassing, mouth hanging open, belly jiggling, uncontrolled, ridiculous laughter that really takes over your body, you can't stop laughing. That laughter will take you all the way through the end of a stress cycle.

BB: Oh my God, I just think that is so good.

EN: It can even help just to reminisce with someone about a time that you laughed that way.

BB: I just know this is true. I love this, you quote Sophie Scott, who's a neuroscientist here, that "laughter is an ancient evolutionary system that mammals have evolved to make and maintain social bonds and regulate emotions." You know, it's true, it comes up in my shame work a lot too, because shame is a universal affect or experience, and laughter is a universal language. And so it's really weird, even my therapist friends who run very difficult groups like sexual assault survivor groups or incest survivor groups, always tell me they can measure the progress of the group by the amount of laughter, and it's not a kind that's like posing or the social lubricant, it's also not that uncomfortable pained like laughter as self-deprecation or deflection, it's knowing laughter. It's almost sometimes laughing at the absurdity that we think we're the only ones. It's just... Laughter is just important. Okay, next, I love this, I love this, and I love what you write about it. You write affection is the next one. "A warm hug in a safe and trusting context can do as much to help your body feel like it has escaped a threat as jogging a couple of miles and it's less sweaty."

EN: Yeah, the 20-second hug, which is... There's a lot of different research disciplines that this comes from. I heard about it from Suzanne Iasenza who's a sex therapist in New York City. She calls it hugging until relaxed, where you hold your body against someone else's and you're not leaning into each other sort of one person step back, the other person will fall down, you're both holding your own center of gravity, you wrap your arms around each other and you stay there, breathing together until you feel the shift in your chemistry. And that's your body going, "I have come home to a place of safety, and I know that because my body feels safe with this other person pressed against it."

BB: God. Let me just read this, "the research suggests a 20-second hug can change your hormones, lower your blood pressure and heart rate and improve mood, all of which are reflected in the post-hug increase in the social bonding hormone, Oxytocin."

EN: And it's not about the 20 seconds.

BB: It's not about the time, it's about leaning in, maintaining your own center of gravity, and just the vulnerability and intimacy of that.

EN: It's a potentially awkwardly long time to hug somebody.

BB: It really is, but I like it. I like it.

EN: Of all the tips we give, it's the one people are most likely to say that they incorporate into their life.

BB: Yeah, I believe that. Okay, the last two, a big old cry. "Anyone who says crying doesn't solve anything doesn't know the difference between dealing with the stress and dealing with the situation that causes the stress." Say more.

AN: Yeah, it's pretty rare that crying will solve a problem or eliminate a stressor. That's true that it doesn't solve that, but what it can do is when the emotion takes over your body, that's a physical expression of stress, of emotion. And when you allow it to complete, it's completing a stress response cycle and letting the emotion go all the way to the end, so it's not getting trapped in your body. And there is a kind of a trick to how to do this if it's hard for you. It was hard for me, I had to learn how from a therapist, how to cry, which is to whatever is overwhelming you and flooding you and causing you to cry, you set that information aside for a moment and you turn toward the physical experience of crying. How many tears, how hot do I feel? Where's the tension in my body, how much snot is pouring out of my nose? And you just pay attention to the sensation of the crying itself without feeding it more thoughts about the thing that sparked the crying, and it ends. It's a cycle, it begins on its own, it has a middle and it ends on its own.

EN: Usually just takes a few minutes too. People are afraid that if they let themselves cry it will last forever. But if you don't continue feeding it thoughts about the cause of the stress, really five minutes maybe.

BB: Okay, the last one, I'm such a fan of this one. Creative Expression.

AN: Yeah, me too, me too.

BB: Says the conductor.

AN: Yeah, I mean, so many people go into the arts in the first place because they discover sometime in their youth, they just intuit their way to feeling how good it feels to take whatever is inside you and put it outside you in paint, or in yarn, or in sketching, or in designing and engineering a process to make something work. Look, there's only so much energy in the world, right? It can neither be created nor destroyed. Everything you make that's made out of your energy is partially made out of you, and it's made out of whatever experiences you've had. And so you can knit little booties and they can be made of your rage, and you can get your rage out of your body by creating something and putting it in a safe place outside of yourself or maybe you could even do somebody some good.

BB: Man, we had a very good family friend die, and he was in high school and just a freak accident, and his mother was a dancer, and so her therapist had her choreograph an entire dance around his death. And she would say until she died, she just died recently, that it was the only thing that kept her alive, and not because she kept doing the dance, but that single effort of that dance took her...

EN: The act of creation.

BB: The act of creation.

AN: Yeah, you take something difficult and put it outside yourself.

EN: Carrie Fisher, "Take your broken heart and turn it into art."

BB: Oh, Carrie Fisher. Say that quote again?

AN: "Take your broken heart and make it into art."

BB: Yeah. One of the stressors in my life right now is we just have a lot of hard family stuff going on, we've had a lot of illness, a lot of... And so, I thought it was coincidence until I read this book that I'm doing this massive family photography project right now, and that's one of my great creative loves, is editing photographs and making albums and stuff. And so, it has been so healing for me. Let's review them really quickly. So, these are ways to complete the stress cycle: Physical activity, breathing, positive social interaction, laughter, affection, a big old cry and creative expression.

AN: I want to say one more thing about creative self-expression, because that's directly connected to imagination. You don't necessarily have to take your feelings and put them into a thing that you make or do, you can also just think your way and imagine your way through a story. This is how I learned to do this initially, which is physical activity didn't work for me, never did, but I would get on the elliptical machine and imagine myself as Godzilla tromping the state land grant institution where I was getting my doctorate. And for the first time, I'd get to the end of a workout and feel elated, and powerful, and ready for anything, and it's not because I did anything with my body different, it's because my mind went through the cycle.

BB: God dang, that's powerful. How do we know that we've completed the cycle?

EN: You feel it in your body, your body will tell you, which is the kind of sentence that I say, and Amelia is like, "What does that mean?"

AN: "How does your body... Your body doesn't talk to you, that's bullshit. What do you... No." It turns out your body does tell you; you just have to learn how to listen for it.

BB: Yeah, because given the world that we live in right now, like I can't stay this stressed out because I can't control the stressors.

AN: Yeah. Thank God you don't have to.

EN: And thank God you know how to begin to feel better because if you can't stay well enough to continue dealing with the stressors, you are going to burn out and stop trying to make the world a better place, and we need... Everybody... The world is in a bad enough state right now, we need everybody on board, which means we need everybody taking care of themselves. And if there's anything we learned in the process of writing the book, it is that the cure for burnout isn't and can't be self-care, it has to be all of us caring for each other.

EN: What we realized is that self-care is the fallout shelter you build in your basement, because apparently, it's your job to protect yourself from nuclear war. So we talk about sleep, we talk about stress, get physical activity. Well, that's not going to work if you live in a household where you're the only person who prioritizes your well-being. It requires everybody in the household agreeing that your eight hours of sleep is a priority, and we are going to cordon off that time and space and protect it, so that you can have that time. Self-care requires a bubble of protection of other people who value your well-being at least as highly as you do. So the cure for burnout must ultimately be...

BB: God, that's right.

EN: All of us caring for each other, and right now more than any other. We don't do lean in, we don't do lean down, we do lean on. Lean with. Pick each other up.

BB: I love that you write here, "Don't worry if you're not sure you can recognize when you've completed the cycle, especially if you've spent a lot of years, like your whole life maybe, holding on to worry or anger. You've probably got a whole lot of accumulated stress response cycles spinning their engines, waiting for their turn. So it's going to take a while before you get through the backlog. All you need to do is recognize that you feel incrementally better than you felt before you started. You can notice that something in your body has changed, shifted in the direction of peace. If I was an eight, at an eight on the stress scale when I started and I'm a four now, you can look at yourself and say, 'That's pretty good.'"

BB: So I love that that incremental progress is still massive progress, and a lot of us have been, I don't know, holding on to this stuff forever. Can I read one more thing to you that just blew my mind? "The good news is that stress is not the problem, the problem is that the strategies that deal with stressors have almost no relationship to the strategies that deal with the physiological reactions our bodies have to those stressors. To be well is not to live in a state of perpetual safety and calm, but to move fluidly from a state of adversity, risk, adventure or excitement, back to safety and calm, and out again. Stress is not bad for you. Being stuck is bad for you."

AN: We hear from a lot of women that they... They feel like they need peace and they're aiming for the sense of peace and completion, and they want ideas for how to achieve that. As if wellness is a goal, a state that you reach, but in fact wellness is not a state of being, it is a state of action, it's the freedom to oscillate. There is no gold at the end of the rainbow. The rainbow is the gold.

BB: That's right, I love that. I love y'all. I'm just saying, I'm just saying, y'all are incredible. This is just... This information is just such a gift to us, for all of us that are looking for grit and discipline, this book, Burnout is help and compassion.

EN: Well, that was... That was a nice thing to say. Thanks.

AN: That's exactly what we were hoping to achieve. Yeah.

BB: Well, you did it. And we're grateful for it. So, do you all both have time for a two-minute apiece, rapid fire?

EN: Sure.

AN: You bet.

BB: We'll take one question a time and do both of you. Vulnerability is, fill in the blank.

AN: Worth it.

BB: Emily.

EN: A choice.

BB: Number two, you're called to be really brave, but the fear is real. You can feel it in your throat. What's the very first thing you do?

AN: Usually, when called upon to be brave, I just dive the hell in, maybe because I'm repressing fear or like, I don't know, maybe it's a good thing or a bad, but I just...

EN: Yes, because you're repressing fear, Amelia.

AN: Yeah, it's because I'm repressing fear, but I just dive in, unless there's a bug involved, if there's a bug involved...

BB: I was going to let your sister answer it. I was going to let your sister address that one.

[overlapping conversation]

AN: I scream like a third grader and call my husband.

BB: Okay, what about you, Emily?

EN: Oh, I breathe.

BB: Number three, Amelia, something that people often get wrong about you?

AN: They think that I'm an extrovert because I'm super high intensity and high energy, but no, I'm a strong introvert.

BB: Emily.

EN: Because I'm a sex educator, people assume I have a sex life that looks like a porno.

BB: Got it. Yeah, I could see how that assumption would happen. Four, Amelia, last show that you binged and loved?

AN: Staged on Hulu with David Tennant and Michael Sheen.

BB: Emily.

EN: Oh Schitt's Creek. Got to be.

BB: Favorite movie.

AN: The Color Purple, it's that grab the tissues, I know I'm going to cry movie.

BB: Emily.

EN: Lately, Rogue One, Rebellions are Built on Hope.

BB: Yep. Six, a concert you'll never forget.

AN: Singing the Brahms Requiem with the New York Philharmonic at Avery Fisher Hall.

BB: Emily.

EN: Amelia's doctoral recital. Shit. I'm not crying, you're crying, stop it.

BB: We're all crying now. So yeah.

EN: Amelia's doctoral program put her in the hospital twice. She had a massive panic attack and called me in desperation right before... I was driving to her recital, and I got there...

AN: I had to go on stage and I couldn't stop crying.

EN: She could not stop crying. She was crying when she walked off the stage at end of her recital. I don't remember a single piece of music that she played, but I remember watching her and thinking that I had never been prouder of anything or anyone in my life.

AN: Aww.

EN: Shut up.

BB: I can't take much more of you all. You all have me on the edge. Okay. Number seven, Amelia, favorite meal.

AN: Blue crabs, outside on a picnic table where it's covered in newspaper and everything's crusted in Old Bay, and like a cold beer that's like dripping, condensation and Old Bay. Yeah, crabs and beer.

BB: Emily.

EN: That will work for me, too.

BB: Eight. What's on your nightstand?

AN: Crabs and beer. No, I'm just kidding.

[laughter]

AN: I have a humidifier on my nightstand because I'm a singer.

BB: Makes sense. Emily.

EN: Earplugs, and eye mask, and a book.

BB: Okay, nine, Amelia, a snapshot of an ordinary moment in your life that brings you true joy.

AN: Sitting on the back step watching my dogs romp and play in the yard.

BB: Emily.

EN: Similarly, watching my husband in the backyard playing with the dogs when he doesn't know I'm watching him. He speaks in complete sentences to the dogs.

BB: Sweet. Okay, last one, 10. Amelia, what are you deeply grateful for right now?

AN: Right now, this conversation here, this has been so amazing and the chance to go through all of this stuff with you. I'm grateful for Brené Brown right now. Oh, my hand hit my keyboard, but I'm grateful for this right here.

BB: Me too. What about you, Emily? What's something you're really grateful for right now in your life?

EN: Right now, my whole body is like the most important thing, the most powerful thing to be aware of is sisterhood. So not just Amelia, my actual sister, but the experience of sisterhood, you being with your sister, and the idea of the ways that our book can facilitate a feeling of sisterhood among women.

BB: Okay, last thing I've got for y'all, you both gave us playlists, I'm looking at them right now. We're going to make little mini mix tapes on Spotify with your playlist. They made me laugh so hard. Amelia, you have to tell me what your five songs... What is one thing that your five songs say about you?

AN: Oh, well, the Brahms. See...

BB: Amelia, you have to go from Brahms and Bach to Tom Waits.

AN: Okay, so the Brahms, the second one the Brahms, it's about despair and hopelessness. The Tom Waits is also about despair, get behind the mule in the morning and plow. Ring of Keys is about discovering, you're recognizing yourself in someone else, and I forget what the last one is.

BB: "How can I keep from singing."

AN: Oh now, okay, so my whole place is like a journey from despair into hope. I didn't do it on purpose, but I made a little journey from despair to hope.

BB: You did. Emily, "Sing, sing, sing", Naughty" from Matilda, and then "Make Our Garden Grow", and then the "Disney Polynesian Village Resort Loop". What does your playlist say about you?

EN: The Pierogi song, and "Sing, Sing, Sing" are about my family connections. "Naughty" might as well be my theme song, and "Make Our Garden Grow" definitely is my theme song. "The Polynesian Village Resort Loop" is what I listen to when I'm on a plane, because it is the opposite of being on a plane. So, all of them take me to a psychological place that I periodically need to go to for very specific reasons.

BB: I just love you both, and I'm so grateful. The book is Burnout. I'll let everyone know where to get it and find it. We'll read it together. We'll change the world.

AN: Thanks.

EN: Let's do it.

BB: Bye y'all.

[music]

BB: So, I'm going to keep talking to Emily and Amelia about what we can learn and how we can do this because we are... As we come up on this election cycle, it's just... We're so fried. There's this great quote that I heard in an AA meeting one time, that "if you don't want to burnout, quit living like you're on fire." Yeah. It spoke to me, obviously. Alright, you all, we've got to breathe, we've got to move, we've got to listen to Disney Polynesian Resort music, which just cracked me up because I could hear the soundtrack in my head when they talked about it, and you need to check out Burnout: The Secret to Unlocking the Stress Cycle by Emily and Amelia Nagoski.

BB: You can find them on Twitter, which they have the Feminist Survival Project 2020. It's Twitter.com, their handle is SF as in feminist, S as in survival, P as in project 2020. Also, in the fun news department, don't forget that I'm launching a second podcast, Dare to Lead, coming October 19th. We're going to dig into big topics, trust, accountability, hard conversations, feedback, giving it and receiving it. And you know, receiving feedback is not easy because not everyone that gives us feedback is trained to do it well. I can't wait for us to do this together. Number two, make sure you have a voting plan, my friends. Thanks again. Hang in there. Breathe, move. Stay awkward, brave, and kind. And I'll see you next week. Unlocking U s is a Spotify original from Parcast. It's produced by Max Cutler, Kristen Acevedo and Carleigh Madden and by Cadence13. Sound design is by Kristen Acevedo.

© 2020 Brené Brown Education and Research Group, LLC. All rights reserved.

Brown, B. (Host). (2020, October 14). Brené with Emily and Amelia Nagoski on Burnout and How to Complete the Stress Cycle. [Audio podcast episode]. In Unlocking Us with Brené Brown. Cadence13. https://brenebrown.com/podcast/brene-with-emily-and-amelia-nagoski-on-burnout-and-how-to-complete-the-stress-cycle/

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Brené with Emily and Amelia Nagoski on Burnout and How to Complete the Stress Cycle

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Burnout. We're all experiencing it and we're all desperate for a way through it. In this episode, I talk to Drs. Emily and Amelia Nagoski about what causes burnout, what it does to our bodies, and how we can move through the emotional exhaustion.

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Video interview on trauma, moral injury, resilience and operational policing

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Video interview on trauma, moral injury, resilience and operational policing

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'We might not be in the same boat, but we are all in the same storm'

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Research Brief: Trauma-informed policing 

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Research Brief: Trauma-informed policing 

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By Kristi Hickle

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The National Child Traumatic Stress Network

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Parenting in a New Context: How Trauma can Impact Parenting

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Discusses important topics for providers relevant for working with refugee and immigrant caregivers, with the goal of enhancing mental health providers' and family therapy practitioners' ability to effectively engage, serve, and support refugee and immigrant caregivers.

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'Stress on the brain' video made by young people in Islington

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'Stress on the brain' video made by young people in Islington

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ABS Insight 4 - Trauma Informed Practice - FINAL lo-res

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Does your school have a trauma informed behaviour policy?

Attachment disorders and trauma are impacting students in every classroom across the UK, with statistics claiming that 15.9% have experienced at least one potentially traumatic event in their lifetime.

This blog will identify the impact of traumatic experiences on students and their classroom behaviours and advise on some tried and tested practical approaches that can be used to improve educational outcomes and alleviate the impact of trauma. It will also highlight the importance of integrating self-care techniques for students and staff.

As Dr Sandra Bloom (2007) notes, "Understanding trauma is not just about acquiring knowledge. It's about changing the way you view the world. It's about changing the helping paradigm from 'What is wrong with you?' to 'What happened to you?'

Identifying trauma

Trauma can be defined using seven generalised dimensions, according to Wilson & Sigman, Preventing PTSD in Trauma Survivors, 2000:

1. Threat to life

2. Severe physical harm or injury

3. Receipt of intentional injury or harm

4. Exposure to violence or the loss of a loved one

5. Learning of violence to a loved one

6. Exposure to a noxious agent

7. Causing death or severe harm to another

Traumatic events are external, but they quickly become incorporated into the mind and the body. According to Judith Herman's book, Trauma and Recovery (1992), psychological trauma is characterised by feelings of:

Intense fear

Helplessness

Loss of control

Threat of annihilation

Children and trauma

Children are more vulnerable to the stress of trauma. Their responses to trauma are complex and are different from those of adults. Children's traumatising experiences can compromise all areas of childhood development, including: identity, cognitive processing, ability to manage behaviour, tolerance, moral development, ability to trust self and others.

Children who have experienced trauma will develop "survivor behaviours" and these behaviours help the child to survive extreme psychological stress in a hostile environment. Examples of this can be fighting, running away, substance abuse, shutting down, self-harm, eating disorders, etc.

In a non-threatening environment the children will exhibit these behaviours to deal with their 'uncomfortableness' and anxiety - to these children even a nurturing environment is threatening!

A trauma informed policy

The field of education cannot ignore the issue of traumatic stress if schools are to meet the expectations of parents and the wider community. As Barbara Oehlberg (2008) says:

At a time when schools and teachers are exceedingly stressed and stretched, becoming trauma informed may seem an ambitious and challenging strategy. However, the rewards for everyone involved are real and energising.

A whole school approach

A child, in order to feel safe at school, needs to know that they can approach any classroom teacher, specialist, SLT, HLTA, wellbeing support, or business manager and receive the same response. The response needs to be agreed upon by all staff, practiced, and with an accepted process when things don't go the way we hope. For example,

Assuming complexity, approaching with empathy

Commitment to building trust and relationships. We can never stop working on this. For students and families living with prior and ongoing trauma, each day can bring a new struggle, and school can provide a sanctuary

Connecting with the whole family

Behaviour as a symptom of the problem, not the problem. This is not to say that violence or breaches of safety do not incur serious consequences, but that the consequences include a depth of investigation and a great deal of support

Support children to build the skills that are a struggle for them, and include them in the process

Connection with external agencies, because school can't do it all!

"There is no more effective neurobiological intervention than a safe relationship, the relationship works to bring the brain back into regulation." (Bruce Perry, PhD, MD, researcher & child psychiatrist)

Strategies for working with children impacted by trauma

Clarify your role with the student

Establish yourself as a safe individual

Create an environment of respect

Give the student opportunities to make choices

Talk about safety and what steps you will take to help the student be and feel safe

Connect the student to the appropriate resources and people

Slow yourself down: talk slower, use a lower pitch for your voice, don't use complex sentences, don't use lots of body movements.

Offer self-calming techniques, such as mindfulness, grounding, tracking, positive memories

Teach positive self-talk to students and practice it before you need it.

Use music, exercise, movement, stretching and incorporate more opportunities for humour and laughter in the curriculum (laughter reduces the traumatic response in the brain).

Behavioural strategies for trauma impacted students

Have a predictable environment with clear expectations for behaviour and have structure during the class day - try not to deviate from it often.

Establish a quiet, safe place in the classroom (or a bespoke wellbeing, refocus room) for students to go when they are feeling overwhelmed - it should be a comfortable space away from others, with comfortable furniture. This space should have some sensory materials for students, have pleasant colours, pictures of nature, etc. that students can focus on when emotionally dysregulated.

Practice active listening with students and demonstrate empathy, 10:1 (Ratio of positive to negative statements for traumatised children) active ignoring of negative behaviour, consistent expectations and behaviour plans that are based on rewards systems, not punishment and collaborative problem-solving with students.

Think of ways to reach out to parents/caregivers that involves them in the educational process, deepen your understanding about the community the student lives in and available resources for the student and family.

Self care to prevent secondary trauma

Secondary traumatic stress is the emotional duress that results when an individual hears about the first hand trauma experiences of another. Its symptoms mimic those of post-traumatic stress disorder (PTSD).

Working with traumatised students can be overwhelming so managing personal and professional stress is vital:

1. Recognise that change happens very slowly

2. Know that you may never see the outcomes of your efforts

3. Trust that our simple compassionate gestures are important elements of helping young people in healing and surviving

4. Knowing your limits

5. Improving your understanding of trauma and secondary trauma

6. Taking a time out

7. Seeking support from co-workers, family, friends

8. Professional counselling

Summary

Relationships and feeling safe are the first step to a young person managing their trauma

Not every strategy will work for every child tailor your approach to each student

Students who have experiences trauma still need clear boundaries and routines

Students need a safe space and trusted adults in order to regulate their emotions

Self care and recognising your limitations is vital when working with young people who have experienced trauma

Further reading and training

See Louise Bomber's book Inside I'm Hurting: Practical Strategies for Supporting Children with Attachment Difficulties in Schools

Also, Attachment in the Classroom: The links between children's early experience, emotional well-being and performance in school: A Practical Guide for Schools by Heather Geddes

Training is offered by Kate Cairns Associates

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Does your school have a trauma informed behaviour policy? Attachment disorders and trauma are impacting students in every classroom across the UK, with statistics claiming that 15.9% have experienced at least one potentially traumatic event in their lifetime.

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Great UK-based resource on TiP and women 

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Great UK-based resource on TiP and women 

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mirror-next-hop.forbes.com | Access denied (403)

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For further information, do not hesitate to contact us.

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Council Post: The Importance Of Trauma-Informed Design

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Trauma-informed design is about integrating the principles of trauma-informed care into design with the goal of creating physical spaces that promote safety, well-being and healing.

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Scotland's national trauma training programme

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Scotland's national trauma training programme

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National Trauma Training Programme - Home

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What is the National Trauma Training Programme (NTTP)?

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The Beacon House Resource Advent Calendar 2021

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www.beaconhouse.org.uk has created an advent calendar for you! Happy holidays! :)

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Organisational resource: Road Map to Trauma Informed Care 

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Organisational resource: Road Map to Trauma Informed Care 

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Road Map to Trauma Informed Care

Check out the TIO Road Map to TIC, which offers phases to the implementation process. Each phase contains a marker(s) along the road that is integral to implementing that phase. When clicking on the road or phase sign, a hover box provides a description of that phase and leads you to the steps, actions, and resources that are helpful for implementation.

Source: Trauma Informed Oregon

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Road Map to Trauma Informed Care * Trauma Informed Oregon

# data[].attributes.attachment_link.description
Check out the TIO Road Map to TIC, which offers phases to the implementation process. Each phase contains a marker(s) along the road that is integral to implementing that phase. When clicking on the road or phase sign, a hover box provides a description of that phase and leads you ...

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We're delighted to announce the beta launch of the Social Work Organisational Resilience Diagnostic (SWORD). SWORD offers adiagnostic surveyand anonline workbookdesigned for use across the whole social work and broader social care profession. SWORD 2020 includes a set of questions exploring staff wellbeing in the context of working under lockdown and social distancing conditions.

In the Podcast Dez Holmes, Director of Research in Practice, briefly discusses resilience within the wider workforce.

About the Social Work Organisational Resilience Diagnostic

The diagnostic enables the collection and analysis of data from professionals working in social care across your organisation to assess organisational health and highlight priority areas for improvement. The is open for organisations to participate until 30 October.

The workbook offers targeted, evidence-informed tasks and strategies to support organisational improvements and develop conditions to better support practitioner wellbeing.

Five key domains provide the structure for the survey and workbook:

Secure base - making sure practitioners have a secure base within which to operate.

Sense of appreciation - promoting a culture in which all members of staff feel appreciated.

Learning organisation - ensuring that learning and development is at the heart of an organisation.

Mission and vision - co-producing and communicating a clear mission and vision.

- prioritising the wellbeing of a workforce and taking a systemic approach to reducing stress and enhancing job satisfaction.

The aim of SWORD is to help leaders and managers to create the conditions that enable workers to sustain and develop resilience.

SWORD has been co-produced with the Research in Practice network in a project led by Dr Louise Grant, University of Bedfordshire and Professor Gail Kinman, Birkbeck University of London. The updated workbook has been co-authored by Dr Kelly Alexander, University of Bedfordshire, to include Adult Services and ensure applicability across the whole social care profession.

How to use the SWORD survey and COVID-19 response survey

Organisations must nominate a lead contact in a senior role (such as a Principal Social Worker, Head of Service) who will administer the SWORD survey across the workforce. Nominated contacts should get in touch with claire.williams@researchinpractice.org.uk to ensure the organisation can access the survey.

The lead contact will disseminate and work with teams and individuals to ensure workforce participation in the survey.

Individuals will complete the survey on line and your organisation's data will be collated and analysed by Research in Practice.

Your nominated contact will receive their organisational data returns once the survey is closed and work with management in implementing the tasks and strategies from the workbook.

SWORD 2020 includes a set of questions to assess wellbeing in the context of working under lock down and social distancing conditions. This will be sent to organisations as a supplementary readout of data.

During the beta year feedback will be gathered from participating organisations on their experience of using SWORD.

Further information

To find out more about the project, contact us.

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Assessing social work organisational resilience & wellbeing | Research In Practice

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In the Podcast Dez Holmes, Director of Research in Practice, briefly discusses resilience within the wider workforce. About the Social Work Organisational Resilience Diagnostic The diagnostic enables the collection and analysis of data from professionals working in social care across your organisation to assess organisational health and highlight priority areas for improvement.

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Black Lives, TIC, and Workforce Wellness: Part 1

June 11, 2020

Michelle Lewis, MSW, Kitty Miller, LCSW ,Tonya Jones, MSW, Steffannie Roache, MS, LPC, Charlie McNeely, MA and Anthony Jordan, MPA, CADCII, come together to share what’s alive for them right now and what they see as the intersection between Black Lives/Wellness, Trauma Informed Care (TIC), and Workforce Wellness. Lived experience is shared around racial battle fatigue, the balance between fear and hope, the work of the White people, and Black community wellness.

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TIO Blog | Black Lives, TIC, and Workforce Wellness: Part 1

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June 11, 2020 Michelle Lewis, MSW, Kitty Miller, LCSW ,Tonya Jones, MSW, Steffannie Roache, MS, LPC, Charlie McNeely, MA and Anthony Jordan, MPA, CADCII, come together to share what's alive for them right now and what they see as the intersection between Black Lives/Wellness, Trauma Informed Care (TIC), and Workforce Wellness.

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Open-access article: Trauma informed practices & youth services

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Open-access article: Trauma informed practices & youth services

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Abstract

Trauma‐informed practice has been developing for decades, though much remains unknown regarding how it is understood and practised. Drawing upon focus group data from an evaluation of a trauma‐informed approach (TIA) implemented by an organisation in Southeast England, this paper provides a unique perspective of 31 staff members and 18 young people. Results indicate how choice and control, key elements of a TIA, align with the Capability Approach (CA). The CA is then used as a novel analytic framework to examine the data. A 'Trauma‐Informed Capabilities Approach' is introduced as a holistic, person‐centred way of conceptualising young trauma survivors' well‐being.

INTRODUCTION

This paper aims to contribute to filling these gaps in the literature in several distinct ways: It draws upon qualitative data from an evaluation of a TIA in a large voluntary sector organisation in the United Kingdom where interest is growing but very limited research on TIAs exist (Sweeney et al., 2016); it examines the use of a TIA in youth housing and advice services, which are underrepresented in research on TIAs (for exceptions, see Bebout, 2001; McKenzie‐Mohr, Coates, & McLeod, 2011) and it includes young people's perspectives on receiving services at an organisation that has adopted a TIA. Finally, perhaps the most important contribution to the literature is in the exploration of Sen's Capability Approach (1995) as a distinctive framework for understanding TI practices as a reparative, person‐centred (Braber, 2013, p. 75) way of considering trauma survivors' well‐being. Through a newly conceputalised 'Trauma‐Informed Capabilites Approach' (TICA), these ideas are integrated to facilitate thinking about TI practice through the lens of the CA, thus enabling professionals such as social workers, youth workers, professionals in mental health, housing, education, residential care settings and researchers with a way forward in developing TIAs that move further away from conceptualising trauma responses as 'the embodiment of certain medical and psychological problems' (Harris & Fallot, 2001, p. 13) and towards creating interventions that treat young trauma survivors as whole people, with strengths and capabilities that can be accessed to promote both trauma healing and holistic well‐being.

BACKGROUND

While the research on TIAs indicate their potential for effective and transformative practice, the many gaps in research suggest there is space and potential for new ways of investigating, understanding and interpreting TI practice on the ground. This includes research further exploring practitioners' and service users' perspectives on TI principles and practices, and considering more holistic ways of conceptualising trauma recovery, beyond symptom reduction and improved behaviour. One new way of conceptualising trauma recovery is through the lens of the Capabilities Approach (CA).

The Capabilities Approach

The CA is moral framework and an evaluative approach to measuring well‐being developed by Amartya Sen in the 1980s and 90s, and further developed by Nussbaum ( 2003). The CA conceptualises human well‐being as multidimensional, providing a more holistic 'people centred approach' (Braber, 2013, p. 75), thus opening up space for thinking about trauma recovery in ways that go beyond symptom reduction and improved behaviour. According to Sen, well‐being is best understood as something that is realised through real freedom of choice to achieve the things in life that are meaningful or valuable to a person, marking a radical departure from the more traditional income‐led measures of well‐being (Frediani, 2010). Sen used the term 'functionings' to describe desired outcomes such as achievements, resources and activities that people value and recognise as important to them. The term 'capabilities' is used to describe the freedom to achieve these desired goals or outcomes (or 'functionings'). Applications of the CA are seen across many fields including emerging applications in social work (Gupta, 2017; Braber, 2013) and mental health (Hopper, 2007; Simon et al., 2013), where a broader and more holistic view of trauma recovery is both relevant and timely.

The CA offers a way of situating TIAs within the social and political contexts where young people live and access services, enabling us to see social and political contexts (such as those perpetuating poverty and inequality) as central to physical and emotional well‐being (Gupta, 2017), and thus avoid de‐politicising and de‐contextualising the traumas they experience (McKenzie‐Mohr, et al., 2011). This is particularly relevant for the UK, where interest in trauma and adverse childhood experiences (ACEs) is growing (Parliamentary Office of Science & Technology, 2018), and where both policy‐makers and practitioners working in the context of a neoliberal political environment are at risk of narrowly interpreting the body of evidence on trauma and ACEs as yet another reason to further decontextualise, problematise and isolate traumatised young people and their families (Edwards et al., 2017). Finally, the CA might also provide a framework through which trauma recovery can be viewed as more than a reduction in symptoms, and instead as part of a collective human experience, in which we are all involved in pursuing and promoting well‐being.

METHODOLOGY

The data drawn upon for this study come from a research evaluation commissioned by a large voluntary sector organisation serving young people across South East England through a variety of services such as counselling, alternative education, supported accommodation, youth advice, specialist support for young people at risk of sexual exploitation, and residential care. In 2014, the organisation sought to develop trauma‐informed practice across the organisation. Their approach was informed by the United States Substance Abuse and Mental Health Services Administration guidance for evidence‐based trauma‐informed practice (SAHMSA, 2015) and the Sanctuary Model (Bloom & Sreedhar, 2008), a theory‐based, evidence‐informed whole‐organisational approach to TI practice. In 2015, the organisation commissioned the author to undertake an evaluation of their TIA. Ethical clearance was granted by the University of Sussex Research Ethics Committee and standard principles for ethical research were followed, including informed consent, confidentiality and anonymity. The overall evaluation is reported on elsewhere (Hickle, 2018).

Data for the original evaluation study included quantitative data (e.g. staff retention and safeguarding data, staff and service user satisfaction surveys) and focus groups with young people, frontline staff and managers held at two points in time, near the beginning of the evaluation in November 2014-January 2015 and at the end in March-May 2017. Young people (age 16-25) and frontline staff who participated in focus groups were recruited from housing and youth advice services; the decision to recruit from these services was made as a way of ensuring the experiences of staff and young people in environments characterised by short‐term relationships, change and transition (and thus less likely to have been a focus of prior TIA research) were heard. All staff employed by these services were recruited via email and staff members self‐selected to participate. Staff informed all young people who utilised these services about the research, which took place in the early evening (with a meal provided) and young people self‐selected to participate. No information regarding the presence/absence of participants' trauma symptomology was collected, as Harris and Fallot's ( 2001) conceptualisation of TI practice is not predicated upon the need for service users to disclose traumatic experiences or meet a clinical, trauma symptom threshold.

Through the process of conducting the evaluation, it became increasingly evident that young people spoke strongly about the way in which being given choices, and feeling power and control in their lives, was a primary means of helping them feel safe. This seemed particularly important as these young people are often beholden to numerous service contexts (child protection, criminal justice, education, and housing) that have incredible power in their lives and often limit their choices. Thus, subsequent to reporting on the overall project, a secondary analysis was undertaken to further illuminate the ways in which young people and staff understood and described elements of choice and control in organisational and relational contexts. Secondary analysis is a useful methodology for providing new perspectives that diverge from the initial purpose or intent of the research (Heaton, 1998), enabling certain aspects of the data to be further scrutinised. The data for this secondary analysis were drawn specifically from the 10 focus groups involving 9 managers, 22 members of frontline staff and 18 young people.

Focus groups were audio‐recorded, transcribed and uploaded to NVivo version 11 (a computer‐assisted data analysis software package) during the original evaluation research, and secondary analysis was undertaken in NVivo as well. For the secondary analysis, a theoretical, or deductive approach to thematic analysis was undertaken first to identify instances in which choice and control-two key principles of TI practice (Harris & Fallot, 2001)-were described in relation to safety and trauma healing by staff and young people. Transcripts were re‐read and analysed for instances in which choice and control were explicitly referenced; however, analysis also sought to surface these concepts at the latent, or interpretive level (Boyatzis, 1998; Braun & Clarke, 2006), when experiences of choice and control were implied but not explicitly labelled as such by the participant. Through this reanalysis of the data, it became evident that the way in which choice and control were described by staff and young people aligned with how these constructs are defined and understood within the CA (Sen, 1995, 2005), though to date, the CA has not been considered in the context of TI practice. The CA was then used as an additional analytic framework, with the key concepts of 'capabilities' and 'functionings' identified as apriori themes. The data were read and analysed again to determine the presence of these themes in the context of focus group discussions of TI practice.

RESULTS

Findings will be presented in accordance with the themes identified in the analysis, beginning with a discussion of how choice and control are described by staff and young people within the focus group data in the context of practicing (staff) or receiving (young people) trauma informed services. Next, key concepts from the CA, capabilities (specifically Frediani's ( 2010) notion of 'capability spaces') and functionings (Alkire, 2008), will be discussed as another way of understanding and conceptualising trauma informed practices.

Choice and control

An emphasis on choice and control emerged naturally from focus groups with young people as a means of feeling safe. They described safety as 'secure', feeling like they have control over their lives, believing their concerns are taken seriously, and knowing that confidentiality is maintained (i.e. control over their own information). Young people accessing housing services also expected and needed practical evidence of safety, such as the use of CCTV (' I'm safe because it's like someone's watching you, it feels safe that someone's making sure that the space you're in is... Nothing's going to happen in there .') as way of feeling in control over who enters and influences their living space, or at the very least knowing who is there so that they could make an informed choice about staying or leaving. Young people across all four focus groups spoke about the importance of being given opportunities to make choices, even when the choices in front of them were limited. For example, in one focus group, two young people spoke about disclosing self‐harm and suicidal ideations to staff, describing how staff helped them through these experiences in a way that allowed them to maintain some control over their lives. Danielle explained:

I only really just recently moved in...and I self‐harmed and was suicidal. They had to follow the procedure, they called the paramedic and an ambulance turned up for me, and I think the way they relayed that to me and they helped me with my own care was by saying, 'do you want us to come with you?' While I'm getting shoved into the back of an ambulance. And going through the safeguarding form afterwards, they didn't just forget it, they didn't just say, 'we will contact you if you want us to.' It was, 'come downstairs and we'll go through a safeguarding form with you, which is how we can help you to stop this from happening again, because we care about you'. It wasn't just forgotten or left about like other places do.

This example demonstrates her insight and acceptance of the safeguarding process that staff were required to follow whilst they continued sharing power and offering choice wherever possible. It also provides evidence of how staff practically involved her in decision‐making, even when they were required to make a final decision on her behalf and follow an externally imposed procedure.

Power‐sharing and partnership were demonstrated in other ways as well, when young people recognised that staff members were allowing them to lead discussions, offering them some choice in who they would be working with, where/when to meet, a referral they might make to another service, or in the development of a risk management plan that is ' completely your [young person's] idea and you can change it or add to it and take things off as and when...like if it's working for you, if it's not working for you .' One young person, Greg, explained that being given a choice about whom he works with is how he knows that the organisation is able to help him, as it ' bears you more in mind '.

When speaking about what characterised safe relationships with staff, young people also indicated the importance of having a plan and a sense of predictability from staff, which helped them feel more in control. Several spoke about staff helping to ' give you purpose ', ' have a plan in place ' and providing clear boundaries and expectations. Hannah described how her key worker would always ensure they ended appointments on time, and if Hannah referenced too many issues to discuss in one sitting, her worker would say,

'I'm going to put a pin in that and come back to that later'...It's really helpful. She'll be like, 'oh, we've put a pin in this and a pin in this, which ones do you want to work on?' That's really good because you have a choice. It's not just like 'we're going to work on this'.

Similarly, staff members seemed to understand the importance of helping young people feel in control of their lives through creating plans and ensuring they maintain predictable expectations and boundaries. One staff member, Dawn, spoke about interpreting a young person's distress and feelings of unsafety as a result of lacking control because they did not understand the purpose of the appointment:

And then over time there was a point in the appointment where they were suddenly like, 'oh, there's a plan. I suddenly get it. There's a point to this, I get it. Okay.' And things felt a lot clearer, and suddenly there was a sense of 'I'm happy to be in this room and actually I'm ready to tell you some other things'.

In addition to emphasising choice and predictability directly through interactions with young people, staff also spoke about TI changes in policy and procedure, including the process for collecting rent and giving young people warnings when they present with challenging behaviour. Prior to the TIA implementation, warnings could accumulate, and the young person would eventually be asked to leave. Under the new TIA, this changed so that young people could 'work off' the warnings they accumulated, and in some instances, staff had more freedom to erase the warnings and give young people a 'fresh start'. They reported this ' worked really well and changed a lot of behaviour '. This is an example of giving back some of the power that the organisation held over the young person and providing the freedom and space to make legitimate choices again.

Finally, while staff in focus groups seemed to generally understand the importance of choice and control as key components of a TIA, they spoke less about feeling choice and control in their own working environments. However, those who had regular supervision spoke about choice and control in the context of supervision and the way in which their new group supervision model is facilitated, enabling them to ' have ownership ' over when and how the groups were organised and flexibility in working practices that better met staff members' needs.

Capability spaces

In order for young people to feel safe, in control, and empowered in their interactions with housing and youth advice services, staff had to create a service environment that provided space for young people to achieve a sense of freedom to pursue, in the language of the CA, their desired functionings. Frediani's ( 2010) notion of 'capability spaces' is helpful in conceptualising how a range of factors (i.e. within an individual, a specific programme and across the organisation) influenced young people's ability to convert available resources into functionings. These capability spaces were evident across the dataset, characterised by relationships with staff who enabled young people to feel confident that seeking help from professionals would assist them in achieving what they wanted for themselves. One example of a young person, Bob, whose views exemplify what a capability space looks like, said that staff gives him ' space when I need it, when I'm feeling anxious or just when I want to shut myself away from the world. They understand that I need time to do that to come back to where I was. Because I can support myself, I can cook for myself, I can dress clean .' Bob knows what he wants, he simply needs the space around him to achieve these things, and to feel agentic and powerful within this space. According to Frediani ( 2010), power and agency underlie capability spaces, and understanding one's need for power (and relationship to power structures) are fundamental to establishing these spaces. They are also fundamental components of a TIA, which seeks to empower service users through trauma healing.

Another important way staff created capability spaces for young people was through forming relationships characterised by persistence. Young people often described staff who were available, offered to accompany them on visits, and conveyed a sense that they would go the 'extra mile' to continue checking in with a young person to see if they were okay. Dave explained how he felt when staff members engage persistently with him:

That actually means the world. To do a random phone call...'no, no, I don't want anything, I'm just calling to see if you're okay'. It means a lot and it gives you that little boost... That adds to me trusting in them, actually they potentially might be a big help to me and they do seem like they actually care.

Dave's explanation demonstrates how persistent relationships led to trust, another key component of TI practice. His increased confidence (that they might be able to help him) invokes a kind of widening space around him in which he is able to see and grasp hold of the resources that can help him achieve the things he wants for himself.

In the staff focus groups, the importance of persistence was also understood. For example, in a focus group with housing staff, the group recalled how they all worked as a team to take a TIA with one particularly challenging young person. With the support from her manager (to address her own feelings of secondary trauma), his key worker was able to persist and continue working with him until:

He slowly started coming around, lots of support from us and his social worker, and that consistency and engagement, just being like 'I am here, I am here, I am here and I'm not going anywhere'...he came around and now he is in his own council flat with a great job and he has absolutely smashed it.

Capability spaces were also created through verbal and non‐verbal interactions that made it easier for young people to engage and access the resources intended to help increase their resilience and move forward with their lives. More specifically, both staff and young people mentioned the importance of body language, validating young people's feelings and emotional responses, and the need to create physical and mental space where things begin to feel calmer and ' easier for people that have experienced trauma to deal with '. In these spaces, staff members held responsibility for creating opportunities that young people felt able to access. This is evident in one staff member's reflective question: ' How can we support this person to make it not so painful to keep coming in here and being told the same thing? '

Capability spaces in the working environment

TIAs were initially conceptualised as a way of working across a whole organisation, from direct practice with service users up through the organisational hierarchy, impacting how staff are supported to feel a sense of safety, trust, collaboration, choice and empowerment in their working environments. In staff and manager focus groups, it was not always evident that they were operating in capability spaces, where the resources at their disposal were easily converted into the kind of boundaried and purposeful practice they may have wanted for themselves and others. Instead, they spoke about environments characterised by uncertainty, feeling 'sandwiched' between stressors experienced by service users, line managers and the wider environment in which funding for services continued to disappear. However, capability spaces were evident when power structures were described as enabling staff to feel confident and supported in their work. Several staff used language that metaphorically invoked a sense of spaciousness in relation to taking a TIA: a ' widening, broadening out ' and a ' culture to open your heart out '. This included a new Well‐Being Policy that had been rolled out shortly before the second focus groups commenced and coincided with changes to contracts that allowed 'official' lunch breaks, access to therapy and wellness activities, managers who encouraged their staff to take 'time off in lieu' when they work overtime, and to leave on time each day.

'Functionings': Reinforcing freedom of (informed) choice

An assumed goal in TI practice is trauma healing/recovery, which is generally described as a reduction in unhelpful trauma responses. While this goal is often explicitly measured in TI evaluation research, the nature of focus group data in this study permitted a different approach to considering the desired outcomes-or what the CA has termed 'functionings'-for young people accessing TI housing and youth advice services, beyond simply a reduction in trauma responses to extend to promoting the freedom of informed choice. Throughout the data, young people spoke about what they valued and wanted when accessing services: respect; evidence that a worker had listened to what they said and followed through (or at least tried to) when they requested something; starting with what they felt was important rather than pursuing the achievement of standard (but impersonal) milestones; and receiving information that was useful and relevant to them.

Young people valued authentic relationships with staff in which they were able to feel a genuine human connection. This included simply discussing the high cost of rent in the city; being willing to go ' off script '; getting a sense that staff members were not trying to act out of a position of authority. They spoke about wanting staff to just act ' like normal adults, normal human begins ', ' not like robots ', and they wanted to be treated ' just like a person ', an adult (not a child) and someone who was equally valued: ' they don't look down on you for being just some scum who lives in [here] who has a problem '. This need for connection through shared humanity-an example of a desired outcome, or 'functioning'- was recognised by some staff, who described it as a key component to a TIA: ' I think there is a sense of trying to, in one's practice, to make sure that one is constantly remembering that it's a human being, there is a person here .' Young people did not assume staff could 'fix' things for them, and preferred that they would be professional and honest about what they could provide. They also did not think it was necessarily important that staff knew the details of their traumatic experiences, but felt it was important that they were aware that they had experienced trauma that impacted their behaviour. As one young person, Beth, said it was important for staff to avoid judging you, ' thinking, oh an average person would pick themselves up after that, or something like that. Understanding you and your journey rather than what society expects of young people .' Young people accessing housing services spoke about valuing a personalised approach which placed individuals' needs above any desire to perceive services as universally impartial or fair. This personalised approach was recognised by staff who spoke of starting where the young person is at. A personalised approach is a defining feature of the CA, which was developed in direct contradiction to measures of well‐being that were subjective, standardised, impersonal and often disconnected to people's lived experiences of human suffering and/or flourishing (Braber, 2013).

Throughout the data, the way in which young people spoke about what they need from staff in order to feel safe reinforced the notion that opportunities to make informed choices were examples of key functionings. Through descriptions of how staff enabled them to feel in control of their lives and the decisions made with/for them, they were emphasising the importance of informed choice. When the young person Dave is quoted above describing how he appreciated staff members persistently engaging him, he is explaining how staff are enabling him to make an informed choice about whether or not he should further trust the staff and further engage with the programme. He is being provided with evidence that they can help him achieve his desired functionings.

DISCUSSION

Findings from this study add to the growing body of research evidencing the usefulness of TIAs in practice and indicate how practitioners' interpretation of TI practice generally aligns with young people's own experiences of receiving TI care. This was particularly true in relation to the way that capability spaces were carved out through safe and persistent relationships. It is also important to note that the TIA implemented by the organisation in this study experienced significant challenges throughout the evaluation period, including internal restructuring and the ongoing impact of austerity, which placed pressure on staff to provide support for young people with increasingly complex needs. Focus groups with front‐line staff and management surfaced many of these concerns, thus demonstrating ways in which TIAs can and should encompass the geographic, social and political contexts they are implemented within (McKenzie‐Mohr et al., 2011).

The findings demonstrate how choice and control are intrinsically linked to feelings of physical, emotional and relational safety (Shuker, 2013). Feeling safe is a key component to trauma recovery (Herman, 1992) and together, safety and control comprise two of the five key principles that Harris and Fallot ( 2001) identified in their initial conceptualisation of TI practice. However, the need for choice and control is not only a key component for trauma recovery; Sen ( 1995) found that they are integral for general human well‐being. According to the CA, capability necessarily involves being agentic and having opportunities to influence decisions and circumstances that affect one's own life. It also involves being able to actually achieve what one wants, even when someone else must make a decision for, or on behalf of another individual, as is often the case for young people in this study. In an example given above, staff member Dawn is described as recalling how a young person was frustrated by feeling a lack of control because she did not understand the purpose of an appointment she had to attend in order to continue receiving services she needed. Through the framework of the CA, we might see this as an example of a young person whose feelings of safety (and recovery from trauma) are related to her ability to see a plan was in place. When she understood the plan, she felt more in control of how she might navigate within this plan, and make informed decisions regarding whether or not the plan would help her achieve her own functionings (i.e. desired goals/outcomes).

In considering the experiences of young people in this study, we can also recognise the ways in which their capability, and thus their well‐being, has been hindered by traumatic experiences. In the context of economic development, Sen ( 1995, 2005) considered poverty a capability 'deprivator', and a key finding emerging from this analysis is that traumatic experiences (including poverty) are also depriving people from capabilities. For example, trauma responses developed by a young person to keep safe act as additional barriers to realising their capability as it is curtailed by what makes them feel unsafe, including places, sounds, memories, people and conversation topics they may actively seek to avoid.

Through the framework of the CA, we can see how TI principles are enacted through relationships, interventions and the spaces created intentionally around young people that promote well‐being. Power, agency, choice and control are key concepts within TI practice and coincide naturally with how they are conceptualised in the CA. Where prior research has been limited in identifying exactly what, in a TIA, contributes to positive change, the CA offered a useful lens through which staff and young people's experiences of a TIA can be interpreted and understood.

A trauma‐informed CA

In adopting a CA, practitioners can consider how services for traumatised young people are organised to provide them with real opportunities to make informed choices and engage in genuine self‐direction such that they feel empowered to shape a future for themselves, in a community that values them. This means that adults with decision‐making power find ways of sharing power with them, as young people in this study described. It may be a paradoxical approach for organisations that focus on behavioural measures of stability before giving traumatised young people opportunities to make choices and be in control of the decisions that affect them; however, this study indicates that young people begin to feel safe through choice and control. The CA enables us to consider why choice and control are so necessary-because they are foundational to human well‐being.

Integrating these concepts together into a Trauma‐Informed Capabilities Approach (TICA) represents a new approach that can promote a more holistic way of understanding trauma healing and enable us to consider how TI practices are useful beyond simply reducing trauma symptoms, and towards promoting well‐being. Through a TICA, we can consider how to create capability spaces that enable the development of resilience and facilitate post‐traumatic growth among young people who are given opportunities to pursue their 'functionings'. As a TICA considers trauma healing within the broader context of human well‐being and flourishing, taking this approach may help practitioners avoid the pathologising language that so often accompanies any focus on trauma symptomology. A TICA also aligns with the wider body of research on the benefits of promoting young people's participation in services and decision‐making (Warrington, 2013) and necessarily leaves space for engaging with the wider sociopolitical context in which traumatic experiences occur (McKenzie‐Mohr et al., 2011). For example, service design informed by a TICA might be better placed to identify the ways in which structural conditions additionally traumatise young people and deprive them of capabilities. As a result, they might prioritise resources that ensure young people experience physical safety through the availability of safe and appropriate housing, and relational safety by encountering staff who are culturally responsive (Treisman, 2018) and skilled in engaging with young people's intersecting experiences of oppression and trauma.

Limitations to the study include the potential for self‐selection bias (Collier & Mahoney, 1996) as the sample may not have included staff and services users with more negative perceptions of the TIA and/or the organisation more generally. It also did not include staff and young people with experience of other services in the organisation. Future research should continue to focus on service user perspectives of TIAs, and should also look to identify approaches to service provision that fill needs a TIA alone cannot address, which might include revisiting the robust body of research on other evidence‐informed interventions (Bath, 2017) as it is recognised that simply taking a TIA may not be sufficient for achieving certain outcomes related to risk and stability (Sweeney et al., 2016). Researchers should also consider alternate outcome measures that look beyond a reduction of trauma symptomology and engage with a more holistic understanding of human resilience and well‐being, particularly in TI practice within children's social care where it has already been recognised that outcome measures often miss the complexity and specificity of practitioners' roles (Forrester, 2017).

A limitation in relation to the use of the CA is that it is often considered an abstract concept, even if this abstraction was intentional, as it was initially conceptualised as an overarching framework that could be used in conjunction with other theories (Robeyns, 2003). Thus, the CA is perhaps best thought of as a starting point, rather than a finishing point (Carpenter, 2009), and one way of identifying capabilities as they are tangibly experienced and lived out is through the examination of empirical data (Alkire, 2005). The present study is an example of how empirical data might be used to illuminate a tangible application of the CA and its usefulness in practice. Research should continue to take further steps in making the CA accessible and useful in practice; in the case of research on TI practice, researchers should seek to engage young people in discovering and articulating what 'functionings' they value and want to pursue as part of their journey beyond trauma.

CONCLUSION

The TICA offers a framework that clarifies how TI principles of safety, choice and control are connected, interpreted and embodied in professional practice with young people. In doing so, it is useful as a theory of action (Braber, 2013), illustrating how a trauma‐informed approach can be practically delivered. Organisations and practitioners across a number of disciplines interested in taking the learning from this study forward can also use the CA component of a TICA as an evaluative instrument, through which any TI policy or practice can be scrutinised to ensure that the role of choice and control is understood, prioritised and incorporated into an understanding of trauma healing that moves practice in the direction of holistic well‐being. Conversely, this paper also fills a gap in research on the CA. The CA is not always considered 'user‐friendly', particularly for practitioners (Braber, 2013) and more work is needed to help put the CA into practice. By using the CA in this study, we can see how concepts such as functionings and capabilities become meaningful and tangible within the lived experiences of professionals and young people.

Biography

Kristine Hickle is a Senior Lecturer in Social Work at the University of Sussex.Her research interests include child exploitation and trauma‐informed, participatory approaches to working with young survivors of exploitation and sexual violence. She has substantial experience training multi‐disciplinary professionals on trauma‐informed practice with young people.

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Abstract

Trauma‐informed practice has been developing for decades, though much remains unknown regarding how it is understood and practised. Drawing upon focus group data from an evaluation of a trauma‐informed approach (TIA) implemented by an organisation in Southeast England, this paper provides a unique perspective of 31 staff members and 18 young people. Results indicate how choice and control, key elements of a TIA, align with the Capability Approach (CA). The CA is then used as a novel analytic framework to examine the data. A 'Trauma‐Informed Capabilities Approach' is introduced as a holistic, person‐centred way of conceptualising young trauma survivors' well‐being.

INTRODUCTION

This paper aims to contribute to filling these gaps in the literature in several distinct ways: It draws upon qualitative data from an evaluation of a TIA in a large voluntary sector organisation in the United Kingdom where interest is growing but very limited research on TIAs exist (Sweeney et al., ); it examines the use of a TIA in youth housing and advice services, which are underrepresented in research on TIAs (for exceptions, see Bebout, ; McKenzie‐Mohr, Coates, & McLeod, ) and it includes young people's perspectives on receiving services at an organisation that has adopted a TIA. Finally, perhaps the most important contribution to the literature is in the exploration of Sen's Capability Approach (1995) as a distinctive framework for understanding TI practices as a reparative, person‐centred (Braber, , p. 75) way of considering trauma survivors' well‐being. Through a newly conceputalised 'Trauma‐Informed Capabilites Approach' (TICA), these ideas are integrated to facilitate thinking about TI practice through the lens of the CA, thus enabling professionals such as social workers, youth workers, professionals in mental health, housing, education, residential care settings and researchers with a way forward in developing TIAs that move further away from conceptualising trauma responses as 'the embodiment of certain medical and psychological problems' (Harris & Fallot, , p. 13) and towards creating interventions that treat young trauma survivors as whole people, with strengths and capabilities that can be accessed to promote both trauma healing and holistic well‐being.

BACKGROUND

While the research on TIAs indicate their potential for effective and transformative practice, the many gaps in research suggest there is space and potential for new ways of investigating, understanding and interpreting TI practice on the ground. This includes research further exploring practitioners' and service users' perspectives on TI principles and practices, and considering more holistic ways of conceptualising trauma recovery, beyond symptom reduction and improved behaviour. One new way of conceptualising trauma recovery is through the lens of the Capabilities Approach (CA).

The Capabilities Approach

The CA is moral framework and an evaluative approach to measuring well‐being developed by Amartya Sen in the 1980s and 90s, and further developed by Nussbaum (). The CA conceptualises human well‐being as multidimensional, providing a more holistic 'people centred approach' (Braber, , p. 75), thus opening up space for thinking about trauma recovery in ways that go beyond symptom reduction and improved behaviour. According to Sen, well‐being is best understood as something that is realised through real freedom of choice to achieve the things in life that are meaningful or valuable to a person, marking a radical departure from the more traditional income‐led measures of well‐being (Frediani, ). Sen used the term 'functionings' to describe desired outcomes such as achievements, resources and activities that people value and recognise as important to them. The term 'capabilities' is used to describe the freedom to achieve these desired goals or outcomes (or 'functionings'). Applications of the CA are seen across many fields including emerging applications in social work (Gupta, ; Braber, ) and mental health (Hopper, ; Simon et al., ), where a broader and more holistic view of trauma recovery is both relevant and timely.

The CA offers a way of situating TIAs within the social and political contexts where young people live and access services, enabling us to see social and political contexts (such as those perpetuating poverty and inequality) as central to physical and emotional well‐being (Gupta, ), and thus avoid de‐politicising and de‐contextualising the traumas they experience (McKenzie‐Mohr, et al., ). This is particularly relevant for the UK, where interest in trauma and adverse childhood experiences (ACEs) is growing (Parliamentary Office of Science & Technology, ), and where both policy‐makers and practitioners working in the context of a neoliberal political environment are at risk of narrowly interpreting the body of evidence on trauma and ACEs as yet another reason to further decontextualise, problematise and isolate traumatised young people and their families (Edwards et al., ). Finally, the CA might also provide a framework through which trauma recovery can be viewed as more than a reduction in symptoms, and instead as part of a collective human experience, in which we are all involved in pursuing and promoting well‐being.

METHODOLOGY

The data drawn upon for this study come from a research evaluation commissioned by a large voluntary sector organisation serving young people across South East England through a variety of services such as counselling, alternative education, supported accommodation, youth advice, specialist support for young people at risk of sexual exploitation, and residential care. In 2014, the organisation sought to develop trauma‐informed practice across the organisation. Their approach was informed by the United States Substance Abuse and Mental Health Services Administration guidance for evidence‐based trauma‐informed practice (SAHMSA, ) and the Sanctuary Model (Bloom & Sreedhar, ), a theory‐based, evidence‐informed whole‐organisational approach to TI practice. In 2015, the organisation commissioned the author to undertake an evaluation of their TIA. Ethical clearance was granted by the University of Sussex Research Ethics Committee and standard principles for ethical research were followed, including informed consent, confidentiality and anonymity. The overall evaluation is reported on elsewhere (Hickle, ).

Data for the original evaluation study included quantitative data (e.g. staff retention and safeguarding data, staff and service user satisfaction surveys) and focus groups with young people, frontline staff and managers held at two points in time, near the beginning of the evaluation in November 2014-January 2015 and at the end in March-May 2017. Young people (age 16-25) and frontline staff who participated in focus groups were recruited from housing and youth advice services; the decision to recruit from these services was made as a way of ensuring the experiences of staff and young people in environments characterised by short‐term relationships, change and transition (and thus less likely to have been a focus of prior TIA research) were heard. All staff employed by these services were recruited via email and staff members self‐selected to participate. Staff informed all young people who utilised these services about the research, which took place in the early evening (with a meal provided) and young people self‐selected to participate. No information regarding the presence/absence of participants' trauma symptomology was collected, as Harris and Fallot's () conceptualisation of TI practice is not predicated upon the need for service users to disclose traumatic experiences or meet a clinical, trauma symptom threshold.

Through the process of conducting the evaluation, it became increasingly evident that young people spoke strongly about the way in which being given choices, and feeling power and control in their lives, was a primary means of helping them feel safe. This seemed particularly important as these young people are often beholden to numerous service contexts (child protection, criminal justice, education, and housing) that have incredible power in their lives and often limit their choices. Thus, subsequent to reporting on the overall project, a secondary analysis was undertaken to further illuminate the ways in which young people and staff understood and described elements of choice and control in organisational and relational contexts. Secondary analysis is a useful methodology for providing new perspectives that diverge from the initial purpose or intent of the research (Heaton, ), enabling certain aspects of the data to be further scrutinised. The data for this secondary analysis were drawn specifically from the 10 focus groups involving 9 managers, 22 members of frontline staff and 18 young people.

Focus groups were audio‐recorded, transcribed and uploaded to NVivo version 11 (a computer‐assisted data analysis software package) during the original evaluation research, and secondary analysis was undertaken in NVivo as well. For the secondary analysis, a theoretical, or deductive approach to thematic analysis was undertaken first to identify instances in which choice and control-two key principles of TI practice (Harris & Fallot, )-were described in relation to safety and trauma healing by staff and young people. Transcripts were re‐read and analysed for instances in which choice and control were explicitly referenced; however, analysis also sought to surface these concepts at the latent, or interpretive level (Boyatzis, ; Braun & Clarke, ), when experiences of choice and control were implied but not explicitly labelled as such by the participant. Through this reanalysis of the data, it became evident that the way in which choice and control were described by staff and young people aligned with how these constructs are defined and understood within the CA (Sen, , ), though to date, the CA has not been considered in the context of TI practice. The CA was then used as an additional analytic framework, with the key concepts of 'capabilities' and 'functionings' identified as apriori themes. The data were read and analysed again to determine the presence of these themes in the context of focus group discussions of TI practice.

RESULTS

Findings will be presented in accordance with the themes identified in the analysis, beginning with a discussion of how choice and control are described by staff and young people within the focus group data in the context of practicing (staff) or receiving (young people) trauma informed services. Next, key concepts from the CA, capabilities (specifically Frediani's () notion of 'capability spaces') and functionings (Alkire, ), will be discussed as another way of understanding and conceptualising trauma informed practices.

Choice and control

An emphasis on choice and control emerged naturally from focus groups with young people as a means of feeling safe. They described safety as 'secure', feeling like they have control over their lives, believing their concerns are taken seriously, and knowing that confidentiality is maintained (i.e. control over their own information). Young people accessing housing services also expected and needed practical evidence of safety, such as the use of CCTV (' I'm safe because it's like someone's watching you, it feels safe that someone's making sure that the space you're in is... Nothing's going to happen in there .') as way of feeling in control over who enters and influences their living space, or at the very least knowing who is there so that they could make an informed choice about staying or leaving. Young people across all four focus groups spoke about the importance of being given opportunities to make choices, even when the choices in front of them were limited. For example, in one focus group, two young people spoke about disclosing self‐harm and suicidal ideations to staff, describing how staff helped them through these experiences in a way that allowed them to maintain some control over their lives. Danielle explained:

I only really just recently moved in...and I self‐harmed and was suicidal. They had to follow the procedure, they called the paramedic and an ambulance turned up for me, and I think the way they relayed that to me and they helped me with my own care was by saying, 'do you want us to come with you?' While I'm getting shoved into the back of an ambulance. And going through the safeguarding form afterwards, they didn't just forget it, they didn't just say, 'we will contact you if you want us to.' It was, 'come downstairs and we'll go through a safeguarding form with you, which is how we can help you to stop this from happening again, because we care about you'. It wasn't just forgotten or left about like other places do.

This example demonstrates her insight and acceptance of the safeguarding process that staff were required to follow whilst they continued sharing power and offering choice wherever possible. It also provides evidence of how staff practically involved her in decision‐making, even when they were required to make a final decision on her behalf and follow an externally imposed procedure.

Power‐sharing and partnership were demonstrated in other ways as well, when young people recognised that staff members were allowing them to lead discussions, offering them some choice in who they would be working with, where/when to meet, a referral they might make to another service, or in the development of a risk management plan that is ' completely your [young person's] idea and you can change it or add to it and take things off as and when...like if it's working for you, if it's not working for you .' One young person, Greg, explained that being given a choice about whom he works with is how he knows that the organisation is able to help him, as it ' bears you more in mind '.

When speaking about what characterised safe relationships with staff, young people also indicated the importance of having a plan and a sense of predictability from staff, which helped them feel more in control. Several spoke about staff helping to ' give you purpose ', ' have a plan in place ' and providing clear boundaries and expectations. Hannah described how her key worker would always ensure they ended appointments on time, and if Hannah referenced too many issues to discuss in one sitting, her worker would say,

'I'm going to put a pin in that and come back to that later'...It's really helpful. She'll be like, 'oh, we've put a pin in this and a pin in this, which ones do you want to work on?' That's really good because you have a choice. It's not just like 'we're going to work on this'.

Similarly, staff members seemed to understand the importance of helping young people feel in control of their lives through creating plans and ensuring they maintain predictable expectations and boundaries. One staff member, Dawn, spoke about interpreting a young person's distress and feelings of unsafety as a result of lacking control because they did not understand the purpose of the appointment:

And then over time there was a point in the appointment where they were suddenly like, 'oh, there's a plan. I suddenly get it. There's a point to this, I get it. Okay.' And things felt a lot clearer, and suddenly there was a sense of 'I'm happy to be in this room and actually I'm ready to tell you some other things'.

In addition to emphasising choice and predictability directly through interactions with young people, staff also spoke about TI changes in policy and procedure, including the process for collecting rent and giving young people warnings when they present with challenging behaviour. Prior to the TIA implementation, warnings could accumulate, and the young person would eventually be asked to leave. Under the new TIA, this changed so that young people could 'work off' the warnings they accumulated, and in some instances, staff had more freedom to erase the warnings and give young people a 'fresh start'. They reported this ' worked really well and changed a lot of behaviour '. This is an example of giving back some of the power that the organisation held over the young person and providing the freedom and space to make legitimate choices again.

Finally, while staff in focus groups seemed to generally understand the importance of choice and control as key components of a TIA, they spoke less about feeling choice and control in their own working environments. However, those who had regular supervision spoke about choice and control in the context of supervision and the way in which their new group supervision model is facilitated, enabling them to ' have ownership ' over when and how the groups were organised and flexibility in working practices that better met staff members' needs.

Capability spaces

In order for young people to feel safe, in control, and empowered in their interactions with housing and youth advice services, staff had to create a service environment that provided space for young people to achieve a sense of freedom to pursue, in the language of the CA, their desired functionings. Frediani's () notion of 'capability spaces' is helpful in conceptualising how a range of factors (i.e. within an individual, a specific programme and across the organisation) influenced young people's ability to convert available resources into functionings. These capability spaces were evident across the dataset, characterised by relationships with staff who enabled young people to feel confident that seeking help from professionals would assist them in achieving what they wanted for themselves. One example of a young person, Bob, whose views exemplify what a capability space looks like, said that staff gives him ' space when I need it, when I'm feeling anxious or just when I want to shut myself away from the world. They understand that I need time to do that to come back to where I was. Because I can support myself, I can cook for myself, I can dress clean .' Bob knows what he wants, he simply needs the space around him to achieve these things, and to feel agentic and powerful within this space. According to Frediani (), power and agency underlie capability spaces, and understanding one's need for power (and relationship to power structures) are fundamental to establishing these spaces. They are also fundamental components of a TIA, which seeks to empower service users through trauma healing.

Another important way staff created capability spaces for young people was through forming relationships characterised by persistence. Young people often described staff who were available, offered to accompany them on visits, and conveyed a sense that they would go the 'extra mile' to continue checking in with a young person to see if they were okay. Dave explained how he felt when staff members engage persistently with him:

That actually means the world. To do a random phone call...'no, no, I don't want anything, I'm just calling to see if you're okay'. It means a lot and it gives you that little boost... That adds to me trusting in them, actually they potentially might be a big help to me and they do seem like they actually care.

Dave's explanation demonstrates how persistent relationships led to trust, another key component of TI practice. His increased confidence (that they might be able to help him) invokes a kind of widening space around him in which he is able to see and grasp hold of the resources that can help him achieve the things he wants for himself.

In the staff focus groups, the importance of persistence was also understood. For example, in a focus group with housing staff, the group recalled how they all worked as a team to take a TIA with one particularly challenging young person. With the support from her manager (to address her own feelings of secondary trauma), his key worker was able to persist and continue working with him until:

He slowly started coming around, lots of support from us and his social worker, and that consistency and engagement, just being like 'I am here, I am here, I am here and I'm not going anywhere'...he came around and now he is in his own council flat with a great job and he has absolutely smashed it.

Capability spaces were also created through verbal and non‐verbal interactions that made it easier for young people to engage and access the resources intended to help increase their resilience and move forward with their lives. More specifically, both staff and young people mentioned the importance of body language, validating young people's feelings and emotional responses, and the need to create physical and mental space where things begin to feel calmer and ' easier for people that have experienced trauma to deal with '. In these spaces, staff members held responsibility for creating opportunities that young people felt able to access. This is evident in one staff member's reflective question: ' How can we support this person to make it not so painful to keep coming in here and being told the same thing? '

Capability spaces in the working environment

TIAs were initially conceptualised as a way of working across a whole organisation, from direct practice with service users up through the organisational hierarchy, impacting how staff are supported to feel a sense of safety, trust, collaboration, choice and empowerment in their working environments. In staff and manager focus groups, it was not always evident that they were operating in capability spaces, where the resources at their disposal were easily converted into the kind of boundaried and purposeful practice they may have wanted for themselves and others. Instead, they spoke about environments characterised by uncertainty, feeling 'sandwiched' between stressors experienced by service users, line managers and the wider environment in which funding for services continued to disappear. However, capability spaces were evident when power structures were described as enabling staff to feel confident and supported in their work. Several staff used language that metaphorically invoked a sense of spaciousness in relation to taking a TIA: a ' widening, broadening out ' and a ' culture to open your heart out '. This included a new Well‐Being Policy that had been rolled out shortly before the second focus groups commenced and coincided with changes to contracts that allowed 'official' lunch breaks, access to therapy and wellness activities, managers who encouraged their staff to take 'time off in lieu' when they work overtime, and to leave on time each day.

'Functionings': Reinforcing freedom of (informed) choice

An assumed goal in TI practice is trauma healing/recovery, which is generally described as a reduction in unhelpful trauma responses. While this goal is often explicitly measured in TI evaluation research, the nature of focus group data in this study permitted a different approach to considering the desired outcomes-or what the CA has termed 'functionings'-for young people accessing TI housing and youth advice services, beyond simply a reduction in trauma responses to extend to promoting the freedom of informed choice. Throughout the data, young people spoke about what they valued and wanted when accessing services: respect; evidence that a worker had listened to what they said and followed through (or at least tried to) when they requested something; starting with what they felt was important rather than pursuing the achievement of standard (but impersonal) milestones; and receiving information that was useful and relevant to them.

Young people valued authentic relationships with staff in which they were able to feel a genuine human connection. This included simply discussing the high cost of rent in the city; being willing to go ' off script '; getting a sense that staff members were not trying to act out of a position of authority. They spoke about wanting staff to just act ' like normal adults, normal human begins ', ' not like robots ', and they wanted to be treated ' just like a person ', an adult (not a child) and someone who was equally valued: ' they don't look down on you for being just some scum who lives in [here] who has a problem '. This need for connection through shared humanity-an example of a desired outcome, or 'functioning'- was recognised by some staff, who described it as a key component to a TIA: ' I think there is a sense of trying to, in one's practice, to make sure that one is constantly remembering that it's a human being, there is a person here .' Young people did not assume staff could 'fix' things for them, and preferred that they would be professional and honest about what they could provide. They also did not think it was necessarily important that staff knew the details of their traumatic experiences, but felt it was important that they were aware that they had experienced trauma that impacted their behaviour. As one young person, Beth, said it was important for staff to avoid judging you, ' thinking, oh an average person would pick themselves up after that, or something like that. Understanding you and your journey rather than what society expects of young people .' Young people accessing housing services spoke about valuing a personalised approach which placed individuals' needs above any desire to perceive services as universally impartial or fair. This personalised approach was recognised by staff who spoke of starting where the young person is at. A personalised approach is a defining feature of the CA, which was developed in direct contradiction to measures of well‐being that were subjective, standardised, impersonal and often disconnected to people's lived experiences of human suffering and/or flourishing (Braber, ).

Throughout the data, the way in which young people spoke about what they need from staff in order to feel safe reinforced the notion that opportunities to make informed choices were examples of key functionings. Through descriptions of how staff enabled them to feel in control of their lives and the decisions made with/for them, they were emphasising the importance of informed choice. When the young person Dave is quoted above describing how he appreciated staff members persistently engaging him, he is explaining how staff are enabling him to make an informed choice about whether or not he should further trust the staff and further engage with the programme. He is being provided with evidence that they can help him achieve his desired functionings.

DISCUSSION

Findings from this study add to the growing body of research evidencing the usefulness of TIAs in practice and indicate how practitioners' interpretation of TI practice generally aligns with young people's own experiences of receiving TI care. This was particularly true in relation to the way that capability spaces were carved out through safe and persistent relationships. It is also important to note that the TIA implemented by the organisation in this study experienced significant challenges throughout the evaluation period, including internal restructuring and the ongoing impact of austerity, which placed pressure on staff to provide support for young people with increasingly complex needs. Focus groups with front‐line staff and management surfaced many of these concerns, thus demonstrating ways in which TIAs can and should encompass the geographic, social and political contexts they are implemented within (McKenzie‐Mohr et al., ).

The findings demonstrate how choice and control are intrinsically linked to feelings of physical, emotional and relational safety (Shuker, ). Feeling safe is a key component to trauma recovery (Herman, ) and together, safety and control comprise two of the five key principles that Harris and Fallot () identified in their initial conceptualisation of TI practice. However, the need for choice and control is not only a key component for trauma recovery; Sen () found that they are integral for general human well‐being. According to the CA, capability necessarily involves being agentic and having opportunities to influence decisions and circumstances that affect one's own life. It also involves being able to actually achieve what one wants, even when someone else must make a decision for, or on behalf of another individual, as is often the case for young people in this study. In an example given above, staff member Dawn is described as recalling how a young person was frustrated by feeling a lack of control because she did not understand the purpose of an appointment she had to attend in order to continue receiving services she needed. Through the framework of the CA, we might see this as an example of a young person whose feelings of safety (and recovery from trauma) are related to her ability to see a plan was in place. When she understood the plan, she felt more in control of how she might navigate within this plan, and make informed decisions regarding whether or not the plan would help her achieve her own functionings (i.e. desired goals/outcomes).

In considering the experiences of young people in this study, we can also recognise the ways in which their capability, and thus their well‐being, has been hindered by traumatic experiences. In the context of economic development, Sen (, ) considered poverty a capability 'deprivator', and a key finding emerging from this analysis is that traumatic experiences (including poverty) are also depriving people from capabilities. For example, trauma responses developed by a young person to keep safe act as additional barriers to realising their capability as it is curtailed by what makes them feel unsafe, including places, sounds, memories, people and conversation topics they may actively seek to avoid.

Through the framework of the CA, we can see how TI principles are enacted through relationships, interventions and the spaces created intentionally around young people that promote well‐being. Power, agency, choice and control are key concepts within TI practice and coincide naturally with how they are conceptualised in the CA. Where prior research has been limited in identifying exactly what, in a TIA, contributes to positive change, the CA offered a useful lens through which staff and young people's experiences of a TIA can be interpreted and understood.

A trauma‐informed CA

In adopting a CA, practitioners can consider how services for traumatised young people are organised to provide them with real opportunities to make informed choices and engage in genuine self‐direction such that they feel empowered to shape a future for themselves, in a community that values them. This means that adults with decision‐making power find ways of sharing power with them, as young people in this study described. It may be a paradoxical approach for organisations that focus on behavioural measures of stability before giving traumatised young people opportunities to make choices and be in control of the decisions that affect them; however, this study indicates that young people begin to feel safe through choice and control. The CA enables us to consider why choice and control are so necessary-because they are foundational to human well‐being.

Integrating these concepts together into a Trauma‐Informed Capabilities Approach (TICA) represents a new approach that can promote a more holistic way of understanding trauma healing and enable us to consider how TI practices are useful beyond simply reducing trauma symptoms, and towards promoting well‐being. Through a TICA, we can consider how to create capability spaces that enable the development of resilience and facilitate post‐traumatic growth among young people who are given opportunities to pursue their 'functionings'. As a TICA considers trauma healing within the broader context of human well‐being and flourishing, taking this approach may help practitioners avoid the pathologising language that so often accompanies any focus on trauma symptomology. A TICA also aligns with the wider body of research on the benefits of promoting young people's participation in services and decision‐making (Warrington, ) and necessarily leaves space for engaging with the wider sociopolitical context in which traumatic experiences occur (McKenzie‐Mohr et al., ). For example, service design informed by a TICA might be better placed to identify the ways in which structural conditions additionally traumatise young people and deprive them of capabilities. As a result, they might prioritise resources that ensure young people experience physical safety through the availability of safe and appropriate housing, and relational safety by encountering staff who are culturally responsive (Treisman, ) and skilled in engaging with young people's intersecting experiences of oppression and trauma.

Limitations to the study include the potential for self‐selection bias (Collier & Mahoney, ) as the sample may not have included staff and services users with more negative perceptions of the TIA and/or the organisation more generally. It also did not include staff and young people with experience of other services in the organisation. Future research should continue to focus on service user perspectives of TIAs, and should also look to identify approaches to service provision that fill needs a TIA alone cannot address, which might include revisiting the robust body of research on other evidence‐informed interventions (Bath, ) as it is recognised that simply taking a TIA may not be sufficient for achieving certain outcomes related to risk and stability (Sweeney et al., ). Researchers should also consider alternate outcome measures that look beyond a reduction of trauma symptomology and engage with a more holistic understanding of human resilience and well‐being, particularly in TI practice within children's social care where it has already been recognised that outcome measures often miss the complexity and specificity of practitioners' roles (Forrester, ).

A limitation in relation to the use of the CA is that it is often considered an abstract concept, even if this abstraction was intentional, as it was initially conceptualised as an overarching framework that could be used in conjunction with other theories (Robeyns, ). Thus, the CA is perhaps best thought of as a starting point, rather than a finishing point (Carpenter, ), and one way of identifying capabilities as they are tangibly experienced and lived out is through the examination of empirical data (Alkire, ). The present study is an example of how empirical data might be used to illuminate a tangible application of the CA and its usefulness in practice. Research should continue to take further steps in making the CA accessible and useful in practice; in the case of research on TI practice, researchers should seek to engage young people in discovering and articulating what 'functionings' they value and want to pursue as part of their journey beyond trauma.

CONCLUSION

The TICA offers a framework that clarifies how TI principles of safety, choice and control are connected, interpreted and embodied in professional practice with young people. In doing so, it is useful as a theory of action (Braber, ), illustrating how a trauma‐informed approach can be practically delivered. Organisations and practitioners across a number of disciplines interested in taking the learning from this study forward can also use the CA component of a TICA as an evaluative instrument, through which any TI policy or practice can be scrutinised to ensure that the role of choice and control is understood, prioritised and incorporated into an understanding of trauma healing that moves practice in the direction of holistic well‐being. Conversely, this paper also fills a gap in research on the CA. The CA is not always considered 'user‐friendly', particularly for practitioners (Braber, ) and more work is needed to help put the CA into practice. By using the CA in this study, we can see how concepts such as functionings and capabilities become meaningful and tangible within the lived experiences of professionals and young people.

Biography

Kristine Hickle is a Senior Lecturer in Social Work at the University of Sussex.Her research interests include child exploitation and trauma‐informed, participatory approaches to working with young survivors of exploitation and sexual violence. She has substantial experience training multi‐disciplinary professionals on trauma‐informed practice with young people.

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Introducing a trauma‐informed capability approach in youth services

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Trauma‐informed practice has been developing for decades, though much remains unknown regarding how it is understood and practised. Drawing upon focus group data from an evaluation of a trauma‐informed approach (TIA) implemented by an organisation in Southeast England, this paper provides a unique perspective of 31 staff members and 18 young people.

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It's is normal to feel a whole range of emotions during these extraordinary times. Feeling stressed and anxious is not a sign of you not coping. Use these resources to help look after you and your children's emotional well-being.

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Understanding Trauma: Learning Brain vs Survival Brain - YouTube        

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Understanding Trauma: Learning Brain vs Survival Brain

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Trauma-informed probation practice

Russell Webster

July 15, 2020

Kieran McCartan summarises the evidence base around trauma and Adverse Childhood Experiences in the lives of people who have committed offences.

Last week, the probation inspectorate published another in its new series of specially commissioned research papers aimed at exploring the evidence base underpinning probation practice. Authored by Dr Kieran F. McCartan from the University of the West of England, this paper focuses on the evidence base around trauma and Adverse Childhood Experiences in the lives of people who have committed offences. A trauma-informed approach is promoted which seeks not to re-traumatise with blame and sanction, but to recognise individual strengths and skills, build confidence and re-educate. It is a person first, service user centred approach that is rooted in desistance and strengths-based models, recognising that the causes and impact of trauma are individualised.

Trauma

Trauma is a broad and varied concept, but fundamentally is a severely distressing or disturbing experience that has an impact on an individual or their broader social network. This means that trauma can be psychological, emotional or physical in nature, with examples including societal events/experiences (i.e., natural disasters, terrorist attacks, COVID-19, etc) or personal events/experiences (i.e., interpersonal violence, sexual abuse, break up/divorce, neglect, disabling conditions, etc). Also, trauma can be linked to:

a one-off event (i.e., being a victim of a terrorist attack, a rape);

a series of similar events (i.e. ongoing child sexual abuse or neglect); or

a combination of a series of diverse events (i.e., being a victim of neglect, childhood sexual abuse and parental divorce).

Therefore, the causes and impact of trauma are individualised.

Adverse Childhood Experiences

Building on the research and work on previous trauma and developmental criminology is the idea of Adverse Childhood Experiences (ACEs). ACEs are negative childhood experiences that can, but do not necessarily, impact a person’s behaviour, health, and psychology across their lifespan. The ACEs can be direct or indirect revolving around abuse, neglect, and household dysfunction. While anyone can have one or multiple ACEs, there is a relationship with socio-economic and socio-political factors. Research shows that some populations (i.e., vulnerable populations and populations with a lower social-economic static status) are more likely to have ACEs, with the impact of those ACEs likely to be greater

What is a trauma-informed approach?

Being trauma-informed means recognising the impact that trauma, including but not limited to ACEs, has on an individual and in acknowledging this, providing appropriate support to that person. A trauma-informed approach is a change of perspective from “What’s wrong with you?” to “What happened to you?”. A trauma-informed approach seeks not to re-traumatise with blame and sanction, but to recognise strengths and skills, build confidence and re-educate – embedding new coping skills to enable recognition and regulation of behaviour. Therefore, it fits into the traditional ‘Advise, Assist and Befriend’ mandate of probation and operates within the ‘What Works’ framework to help us address the individual needs of the service user and enable them to desist from offending.

The link between being person first, trauma-informed and desistance

Trauma-informed approaches are rooted in strength-based research and practice (i.e., Risk Need Responsivity and the Good Lives Model) which emphasise that offending behaviour is only one part of the characteristics of an individual. Strengths-based interventions highlight that to reduce reoffending, we need to focus on the positive aspects of the individuals that we work with, their protective factors, not just the risk factors.
Desistance is rooted in the life course and development of an individual and focuses on the way that they can learn to stop offending and change their lives. This is important in terms of reintegration as many people, because of past trauma and ACEs, may not have been fully or appropriately integrated in the first place. Taking a trauma-informed approach enables the service user to recognise that they are being heard, supported, and enabled to change which means that they can own their desistance. Additionally, there are benefits to staff who become enablers of change rather than managers of change. They become fully aware of how desistance can feed into prevention and a reduction in first time offending.

Developing a trauma-informed workforce

In developing a person first, trauma-informed workforce, McCartan argues that  we need to place the individual service user at the centre of the process, allowing their voice to be heard and enabling them to move forward at a sustainable pace; promoting desistance, behaviour change, harm reduction and prevention. A trauma-informed approach can be framed in terms of policy, practice, place, and people:

Policy: Workplaces need to have trauma-informed practice embedded at a policy level, ensuring it is a key plank in all organisational policies and factored into the development of new policies. An organisation can then demonstrate that being trauma-informed is at the core of its ethos and business.

Practice: Being trauma-informed should be part of the day to day practice in an organisation; it should be constantly considered and developed. It should be written into all aspects of the organisation’s activities and be reflected in development, planning and maintenance of all working practices. It should be the subject of clear leadership in all parts of the organisation. This may mean that trauma-informed practice is recognised as a Key Performance Indicator against which all practice is measured.

Place: Being trauma-informed means that you develop a space for service users that is not trauma inducing or triggering, and where they feel able to engage with treatment, rehabilitation or supervision without feeling that they are at risk of relapse. This is a challenge in criminal justice settings, but one that needs to be considered as the shape, layout and flow of a building may have a traumatic impact on service users in general; especially if their traumatic experiences were criminal justice related.

People: Being trauma-informed means training staff in how best to communicate and interact with service users. This involves staff training, appropriate leadership and awareness raising. Being trauma-informed needs to be at the forefront of practice in all forms of communication, support, and interactions, especially with challenging and difficult service users. In addition, having a trauma-informed workforce means a reflective workforce that is supported, supervised, and enabled in a pro-active way.

The header image is reproduced with kind permission of Tom Pumford. It was published on Unsplash and you can see Tom’s work here.

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Systemic resilience in youth justice

Systemic resilience focuses on strengthening the protective factors around the child including within their family, their community, and local services.

3rd May 2022

On Probation

Transitional Safeguarding

Transitional Safeguarding – a more fluid approach which recognises that transition to adulthood goes beyond an 18th birthday.

28th March 2022

On Probation

21st March 2022

On Probation

16th March 2022

2 Responses

1. I recently had a change of probation officer and at first, I mistook her passive demeanour to be anything but helpful, believing that the change in probation officer was perhaps indicative of their going to ramp-up my supervision. I even commented on how stern she appeared, feeling as I had at the time, ‘of hitting the nail on the head.

I am as described in the aforementioned article, an Ace of ACE’s and I sometimes wonder how I’ve managed to make any progress at all.

Several months have now elapsed and I can honestly say that the difference that this individual has made in such a short time has been truly remarkable. I was not aware of this particular initiative within the probation service before I read this article and upon reading it in it’s entirety, can I now appreciate why there had been a supple approach.

Covid19 has exasperated everyone’s perspective and having to isolate, whilst not an altogether intolerable situation for me in particular. It nevertheless meant my not having the regular face to face contact, I had otherwise become accustomed to. I have nevertheless been afforded exceptional contact, albeit over the phone, via emails and indeed by texting. This has been invaluable to me, I am a moaner after all and I need an outlet to ruminate and I consider that this approach will provide a much clearer perspective to enable practitioners to expand on their knowledge on timely intervention strategies. Excellent study, extremely well thought through. Bravo

2. Thanks for taking the trouble to share some positive news.

Best Wishes

Russell

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Trauma-informed probation practice - Russell Webster

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Kieran McCartan summarises the evidence base around trauma and Adverse Childhood Experiences in the lives of people who have committed offences.

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Page not found – NARM Training Institute

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Disclaimer: The NARM Training Institute is neither a regulatory nor licensing organization and therefore not sanctioned to certify, license, or otherwise bestow the legal authorization to practice as a mental health professional. You are responsible for working under your professional license and within your scope of practice.

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What Is Compassionate Inquiry?

Compassionate Inquiry® is a psychotherapeutic approach developed by Dr. Gabor Maté that reveals what lies beneath the appearance we present to the world.

Using Compassionate Inquiry, both the individual and therapist unveil the level of consciousness, mental climate, hidden assumptions, implicit memories and body states that form the real message that words both express and conceal.

Through Compassionate Inquiry, the client can recognize the unconscious dynamics that run their lives and how to liberate themselves from them.

“The purpose of Compassionate Inquiry is to drill down to the core stories people tell themselves – to get them to see what story they are telling themselves unconsciously; what those beliefs are, where they came from; and guide them to the possibility of letting go of those stories, or letting go of the hold those stories have on them …

That’s what Compassionate Inquiry is.”

~ Dr. Gabor Maté

Our Intention

To teach the Compassionate Inquiry approach, developed by Dr. Gabor Maté, so that individuals can connect to the truth within themselves in the present moment, become free from self-generated suffering, and gain insight, clarity and choice in their behaviour.

Our Vision

To bring compassion, respect, acceptance, insight, healing, freedom and connection to humanity through an international community of skillful Compassionate Inquiry practitioners.

Who Can Benefit from Compassionate Inquiry?

The Compassionate Inquiry training and approach will be of benefit to psychotherapists, mental health professionals, health care professionals, allied health professionals, medical doctors, naturopathic physicians, fitness coaches, addiction counsellors, educators, First Nations counsellors and elders, Traditional Healers, psychedelic therapists, plant medicine shamans, therapeutic communities and institutions, yoga teachers, meditation teachers, spiritual teachers, recovery communities, individuals interested in personal development, adult influencers, marginalized groups, diverse groups (in demographics, economics, sex, lifestyle), and multicultural groups (variations in ethnicity).

About Dr. Gabor Maté

Dr. Gabor Maté is a retired physician who, after 20 years of family practice and palliative care experience, worked for over a decade in Vancouver’s Downtown East Side with patients challenged by drug addiction and mental illness. The bestselling author of four books published in twenty-five languages, Gabor is an internationally renowned speaker highly sought after for his expertise on addiction, trauma, childhood development, and the relationship of stress and illness. His book on addiction received the Hubert Evans Prize for literary non-fiction.

For his groundbreaking medical work and writing he has been awarded the Order of Canada, his country’s highest civilian distinction, and the Civic Merit Award from his hometown, Vancouver. His books include In the Realm of Hungry Ghosts: Close Encounters With Addiction; When the Body Says No; The Cost of Hidden Stress; Scattered Minds: The Origins and Healing of Attention Deficit Disorder; and (with Gordon Neufeld) Hold on to Your Kids: Why Parents Need to Matter More Than Peers. To learn more, join his enews list at www.drgabormate.com.

About Sat Dharam Kaur ND

Sat Dharam is a naturopathic doctor, Kundalini Yoga lead trainer, and author, practicing in Owen Sound, Ontario. She facilitates Kundalini Yoga teacher training programs in Toronto and internationally. She developed the Beyond Addiction: The Yogic Path to Recovery program, and has been working closely with Dr. Gabor Maté in delivering this program along with the Compassionate Inquiry training. She also developed the Healthy Breast Program, designed to help educate women globally in reducing breast cancer risk, and co-founded the MammAlive Foundation. Sat Dharam was awarded the Naturopathic Doctor of the Year award in Ontario in 2000. She has written three books: A Call to Women: The Healthy Breast Program and Workbook, The Complete Natural Medicine Guide to Breast Cancer, and The Complete Natural Medicine Guide to Women’s Health.

About the Program

Dr. Maté teaches workshops where he models the process of Compassionate Inquiry with course participants, which serves to instruct therapists in the practice of this powerful technique to help clients access deep healing and transformation. Upcoming live workshops, and workshop recordings can be found here.

The online training and curriculum was developed by Sat Dharam Kaur N.D. and contains video and audio recordings and transcripts from 5 Compassionate Inquiry workshops taught by Dr. Maté. The first training was offered in January 2019.

Click here to learn more about the online program.

In the Compassionate Inquiry training, you will learn:

how to cultivate presence, being with what is

to bring attention to body signals in clients and yourself

to enhance your perception of what is not being revealed overtly

to enable clients to access emotional states through body awareness

how to create and maintain a safe sacred space between client and therapist

how to facilitate the expression of what has remained unexpresssed

how to keep a client engaged in present moment experience

the importance of patience, respect and choice in the therapeutic process

how to uncover early traumatic events of childhood and unconscious feeling states through Compassionate Inquiry

Sign up to the Compassionate Inquiry Newsletter for updates!

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Compassionate Inquiry® is a psychotherapeutic approach developed by Dr. Gabor Maté that reveals what lies beneath the appearance we present to the world. Using Compassionate Inquiry…

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Introduction

Expert evidence

Toolkit sections

Impact of sexual assault

Mental Health Conditions - Neurodevelopmental disorders

Mental Health Conditions - Schizophrenia and other psychotic disorders

Mental Health Conditions - Affective disorders

Mental Health Conditions - Anxiety, stress-related and somatoform disorders

Mental Health Conditions - Substance use disorders

Mental Health Conditions - Conduct and Personality disorders

Specific considerations for children

Recall, memory and diagnosis

Conclusions

Contributors

Annex A – How prosecutors should use this toolkit

Introduction

When a complaint is made, the understanding of pre-existing mental ill health, and potential psychological reactions to sexual assault and its aftermath, are vital considerations for a number of reasons. When a victim seeks help and discloses what has happened, the individual’s (and society’s) response is of paramount importance, and one determinant of the victim’s future psychological well-being. If the victim has chosen to disclose to the police and thus become a complainant, they are often aware that a series of events and interactions will follow. Those people whom they subsequently encounter through the judicial process will make judgements based on their own belief systems. Attitudes might affect questioning, evidential acquisition, victim response, decisions about proceeding and juror deliberations. So beliefs held, when myth rather than reality, may have a crucial role to play both in terms of well-being, and in achieving justice.

Rape and serious sexual assault can affect many areas of an individual’s life for many months and sometimes years following the attack. In addition to experiencing psychological difficulties, the complainant may suffer ongoing physical problems, resort to alcohol or drug abuse, experience alterations to their day-to-day behaviour and find that their thought processes are very different, as a direct consequence of the attack.

Psychological and physiological reactions occurring at the time of the trauma can have an impact upon the individual’s ability to give a coherent, consistent account of their experiences. Subsequent changes to the victim’s account of events may be viewed as evidence that they cannot be believed. Post-traumatic symptoms will also potentially affect recall and consistency - indeed an inability to recall aspects of the event is one characteristic symptom of PTSD (post-traumatic stress disorder). Victims experience feelings of shame and self-blame and this may result in an incomplete or inaccurate account of the circumstances surrounding the assault. Cultural issues may have a significant impact, as may the stage of development, if the victim is a child.

It is also important to note that for a proportion of those assaulted, pre-existing mental health problems will also be a factor. Over recent years there has been increasing recognition of the vulnerability of many of those reporting rape and serious sexual assault – mental health vulnerabilities may make individuals more likely to be victims, and less likely to report these offences to the police. The CPS acknowledges that “barriers exist, which mean that some people are less likely to report offences. People with learning difficulties or mental health problems may feel that they will not be believed if they report being raped.” (Crown Prosecution Service Commitments to Support Victims and Witnesses (Legal Guidance), Rape and Sexual Offences, Chapter 5, CPS publications (2012).

Expert evidence

There is increasing interest in the role of experts in sexual offence cases, in terms of the value they may add to successful prosecutions. Both psychiatrists and psychologists may have expert knowledge that could be of assistance to the Court, though confusion can arise as to the differences between the two. Questions may also arise about psychotherapists. Psychiatry is a medical specialty; psychiatrists must first qualify as a doctor, then spend two years in “Foundation” general medical and surgical jobs before they can start to specialise in psychiatry. It usually takes a minimum of another four years to pass the two professional exams of the Royal College of Psychiatrists, after which they can specialise further. Like other areas of medicine, psychiatry builds its knowledge through the observation of unusual and distressing conditions. It uses a diagnostic system, which tries to identify clusters of thoughts, feelings and behaviour that seem to occur together – known as “syndromes”. These are then investigated to find social, psychological and any physical causes, with a view to finding effective ways of helping. Psychiatrists tend to work with people who have more severe disorders that may require some sort of medical treatment. This often, but not always, involves the prescription of medication. A psychiatrist can take into account psychological and social factors and will tailor any treatment plan according to the needs of the individual.

People who undertake a psychology degree may refer to themselves as psychologists, but there is a range of further training that can lead to a qualifying specialism. One of these is clinical psychology. A clinical psychologist will have gained a degree in psychology at university, and then will have undertaken a three year doctorate in clinical training in an approved training scheme. They learn several models of psychological therapy and develop an ability to work consultatively. They also learn research methods and skills in service development. Psychology has historically applied a more formal experimental approach to exploring both normal and abnormal states of mind, with the emphasis more on clarifying psychological mechanisms rather than physiological ones.   A psychotherapist can come from any professional background, including medicine and psychology – or none. However, psychotherapy training is usually quite separate from either of these disciplines, and there is no mandatory regulation of psychotherapy.

Within both psychiatry and psychology individuals may specialise in work in the trauma field, and may undertake further training that qualifies them as a forensic psychologist or psychiatrist. Such individuals will have legal training and will generally be more used to working with offenders, appearing in court, and understanding the impact of trauma.

It is not unusual for the defence to obtain reports from other experts, from a range of specialties. It is important to actually understand their expertise, as it is not always related to the matters on which they comment, and will require robust challenge on occasions. This may be due to a lack of availability of appropriate experts for the case, but there is a danger in recruiting the wrong expert and it may mislead the court to do so.

Toolkit sections

This guidance provides information in relation to the psychological impact of sexual assault, a range of relevant mental health conditions, as well as some principles for working with child victims; it will assist prosecutors with the task of assessing evidence provided by a witness suffering from a particular condition or conditions, and provides advice on working with young people. The document highlights where expert comment may be required to facilitate a fair assessment of the evidence.

It also highlights the specific support that an individual suffering from a particular condition is likely to require during their journey through the criminal justice process, and provides guidance on how to effectively adjust the approach taken, in order to account for the impact of a condition, which is vital in the interests of justice.

The guidance is arranged into diagnostic clusters given the many similarities that will exist between diagnoses within those clusters. The guidance also contains information about the general impact of sexual assault, and on memory and recall following sexual assault. Recommendations for managing the cases of young people who are victims of assault are also included.

Currently two discrete classification systems are used for the diagnosis of mental disorders: the International Classification of Diseases (ICD 10), (World Health Organisation.(1992).International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10). Geneva: WHO), which is used by most countries internationally, and the Diagnostic Statistical Manual (DSM 5), (American Psychiatric Association (2013). Diagnostic and statistical manual of mental health disorders (5th edition). Washington DC), which is the preferred research reference text in the USA. Similarities between diseases within these systems and where possible the alternatives to the ICD 10 name (for example, the DSM 5 diagnosis, or commonly used terms) are included in brackets.

Conditions such as dementia and brain injury, are not currently included in this toolkit, and it would be advisable to seek direct specialist advice in these circumstances, as the impact of these conditions will be nuanced depending on the degree of damage to the brain in each individual.

Prosecutors should refer to Annex A ‘How prosecutors should use this toolkit’ which provides more detail with regards to the purpose of the toolkit and the importance of prosecutors not using the toolkit to justify proceeding with cases which fail to meet the Full Code Test.

Impact of sexual assault

It is essential to understand the impact that the trauma has upon the brain and our functioning, since if the mechanisms outlined below are not understood, then the evidence gathered will be less informative than it might otherwise have been.  Questions will be based on false assumptions, and vital information may be missed.

Traumatic experiences such as sexual assault can lead to:

Derealisation

Depersonalisation

Dissociation

Terror, confusion, disorientation, helplessness and loss of physical control.

These processes mean that some people may not resist an attack, run away or cry for help. Indeed, they may just appear frozen, and unable to act. Some may submit to sexual intercourse from fear of what might happen if they were to resist it, or even merely to protest. Victims may be constantly re-evaluating their situation during the attack and so may change their behaviour accordingly. The fact that a person who had initially protested or resisted stops doing so during the attack does not necessarily mean that they are now consenting to it. Submission or adopting a passive stance, and therefore allowing the attacker to do what they want, is not the same as consent, and may stem from fear.

A victim may also seek to limit danger to others, for example, children. If the victim is afraid that their attacker will become more dangerous or violent if they do not do what they are told, then they may not argue or fight back, but rather will agree to do what is asked, rather than risk the consequences of not doing so. It may be that even after the event, the victim will not seek to get away at the earliest opportunity. This may be because they perceive ongoing danger and are trying to act normally to appease the attacker.

Derealisation, depersonalisation and dissociation may severely impair the person's ability to recall details of the assault and recall may change over time.  Memories of traumatic events are often organised on a perceptual, rather than verbal level, at least in the initial phase following the trauma.  Feelings and emotions can be recalled, but a detailed narrative cannot be given. Thus, questions asked should focus on perceptions (what did you feel/smell/hear and so forth).  With further questioning, and processing of the event (for example by talking it though with a friend, or support worker) more of the narrative component may become accessible, and the victim’s account may change.  Difficulties with altered accounts and variable recall will be familiar, and once again, understanding the psychological processes behind these difficulties can only facilitate successful prosecution.  An inability to access the traumatic memories may make the giving of very detailed evidence in court impossible and the person may be seen as lying or incompetent. Other important features of peritraumatic dissociation include:

Losing track of what was going on

Doing things that individuals later realised they had not actively decided to do

A sense that time altered, for example “things seemed to be happening in slow motion”, or “at speed”

Sensory disturbances, for example moments when their body seemed distorted or changed.

A number of factors will determine the response that individuals demonstrate following sexual assault. These include:

Factors | Responses

Pre-existing individual variables

Mental ill health

Previous exposure to trauma, including sexual and domestic abuse

Preparedness

Stressor variables

Unpredictability

Suddenness

Threat to life (real or perceived)

Receiving intentional harm

Relationship to perpetrator

Responses of external world

Lack of support

Institutional avoidance

Victim blaming

Specific experiences of the individual

Belief that one was going to die

Witnessing grotesque sights

A sense of hopelessness and resignation

Attributions

Cultural beliefs

Anger

The vast majority of individuals subject to sexual assault will experience an acute stress reaction with feelings such as shock, numbness and distress. In the early weeks and months, most individuals will experience psychological symptoms such as anxiety, depression and tearfulness, guilt, shame, disbelief, physical revulsion and helplessness.  Some will go on to develop PTSD, and many victims of sexual assault also develop depressive symptoms. The majority seem to recover from the acute effects of the attack at between 3 and 4 months, however, for a significant proportion of incident survivors these feelings do not go away and can persist for many months and sometimes years post-trauma.

Thus, included within this guidance are descriptions of a range of difficulties, some of which may precede the sexual assault, whilst others, such as depression, anxiety, substance abuse and PTSD, may arise as a consequence of the sexual assault.

Mental Health Conditions - Neurodevelopmental disorders

Introduction

Neurodevelopmental disorders are a group of conditions that are evident early in development and include generalised learning disabilities, autism spectrum conditions and hyperkinetic disorders (“attention deficit hyperactivity disorder or ADHD”). These individuals tend to have life-long difficulties related to interaction with their environment and functioning in a social context, and this also often affects personality development.

People with neurodevelopmental disorders may face considerable challenges and they tend to have higher rates of mental illnesses, and may have associated shorter life expectancies and worse health outcomes than the general population. They often face stigma, high rates of abuse and more limited opportunities in life, and are often highly vulnerable to victimisation.

Diagnoses

Intellectual disability (also known as ID/learning disability/LD/mental handicap/mental retardation), (ICD 10 classification)

Pervasive developmental disorders (also known as PDD/autistic spectrum disorder/ASD/Asperger's syndrome/autism/high-functioning autism/pathological demand avoidance/PDA)

Hyperkinetic disorders (also known as attention deficit/hyperactivity disorder, ADHD)

Presentation and symptoms

Learning disability includes the presence of:

a significantly reduced ability to understand new or complex information or to learn new skills (impaired intelligence);

a reduced ability to cope independently (impaired social functioning)

onset before adulthood, with a lasting effect on development.

This definition encompasses people with a broad range of disabilities. The presence of a low intelligence quotient (e.g. an IQ below 70), is not, of itself, sufficient reason to conclude that an individual has learning disabilities, and wider clinical assessment is required before the diagnosis can be made confidently (Valuing People: a new strategy for learning disability for the 21st Century, Department of Health publications, 2001). Learning disability is commonly divided into borderline, mild, moderate, severe and profound diagnostic groupings. Individuals with learning disabilities may have aptitudes in some areas but marked deficits in others, and may experience challenges in cognitive processes, educational and vocational settings, and in emotional and social interactions.

Autism, which may or may not include a learning disability, is a lifelong developmental disorder that affects how people perceive the world and interact with others. People with autism may see, hear and feel the world differently to other people. Autism cannot be cured, but people can learn to live with the symptoms if equipped with appropriate coping strategies, or can be managed in a setting which takes into account their needs.

Autism is a spectrum condition, meaning that some people will experience very few difficulties and can function normally in society without additional support, whereas some people may be very severely affected and may struggle with speech, self-care and any form of social interaction. All autistic people share certain difficulties (usually grounded in social communication problems), but being autistic will affect them in different ways. Some autistic people also have learning disabilities, mental health issues or other physical health conditions, meaning that individuals need different levels of support.

A person with autism may have a completely different view of their surroundings and the social context of their day to day living. Some people with autism say the world feels overwhelming due to multiple different types of stimulus causing confusion, and this can subsequently result in considerable anxiety. In particular, understanding and relating to other people, and taking part in everyday family, school, work and social life, can be harder, and require considerable effort to keep up with the normal interactions seen in their peers. People with autism may wonder why they are 'different' and feel their social differences mean that people do not understand them. The characteristics of autism vary from one person to another, but in order for a diagnosis to be made, a person will usually be assessed as having had persistent difficulties with social communication and social interaction, and restricted and repetitive patterns of behaviour, activities or interests since early childhood, to the extent that these difficulties limit and impair everyday functioning.

ADHD (hyperkinetic disorder) is now one of the most prevalent psychiatric diagnoses in children. However, it is less known that a substantial proportion of children with ADHD continue to have problems in adulthood. In fact, when ADHD is not recognized, children might be considered to be being ‘naughty’ or ‘lazy’, and many of these children grow up to be adults that have not been able to complete secondary education and/or to find or keep a job, and may end up with addiction problems or being involved in criminal behaviour. ADHD symptoms include pervasive (i.e present in different social contexts) inattention, hyperactivity and impulsiveness, inappropriate for the individual’s age. Many children outgrow much of their hyperactivity and impulsivity and this also holds true for children with ADHD. This means that some of the hyperactivity and impulsivity symptoms will become less problematic when children get older, and might be non-existent once they have reached adulthood. In contrast, symptoms of inattention tend to be much more perseverant and research has shown that ADHD-related concentration problems are relatively stable over time.

Treatments and their implications for trial

Learning disabilities and autism are lifelong conditions, which can cause a number of difficulties in court settings. Treatments are geared towards familial and social adaptations that can assist the individual, and therapeutic approaches to enable the individual to better understand and function in the world. Medication can be used occasionally, and low-dose antipsychotics can be helpful. These medications must be taken regularly to be effective, and their side effects can include sedation which may cause difficulties in retaining information in a trial setting. Issues of effective communication may be apposite in considerations about proceeding to trial.

A biopsychosocial approach is taken with individuals with ADHD (hyperkinetic disorder). This includes working with families and social work teams, direct psychological work with the individual and on occasion, typically a stimulant medication (for example methylphenidate, also known by trade names of “Ritalin” or “Concerta”).

The medical treatment of hyperkinetic disorders can have implications in trials. Most medication would need to be at a therapeutic dose one week prior to the trial (and after initiation, dose adjustment normally occurs on a weekly basis until the right dosage has been achieved). Whilst its speed of onset is rapid (usually 2-3 days), medications for hyperkinetic disorders cannot be taken intermittently - these medications do have side effects, one of which is insomnia, which may cause tiredness and worsened inattention if the next day’s dose is missed. Obsessive-compulsive symptoms may occur if the dosage is too high, which may cause difficulties for individuals in focusing on changing information during trials. A specialist should oversee medication prescription and it would be useful to confer with that doctor or seek other expert medical advice pre-trial, to ensure that the individual is unimpaired in their ability to participate effectively.

Potential legal implications

A number of cases have been the subject of criticism at the level of the Appeal Court and European Court where neurodevelopmental disorders (SC v United Kingdom (2005) 40 E.H.R.R. 10), developmental immaturity (T v. United Kingdom – Application No. 24724/94, ECtHR; V v. United Kingdom – Application No. 24888/94, ECtHR) and hyperkinetic disorders (R. v. Billy Friend [2004] EWCA Crim 2661) have not been properly acknowledged in terms of their potential impact in relation to effective participation.

Individuals may appear restless or inattentive in the course of a trial as they struggle to focus on the proceedings, which is likely to give a poor impression to the jury unless they are properly informed of the likely impairments – individuals may be assumed, by the lay person, not to be affording the proceedings their due gravity, or their testimonies may be considered less reliable as a result of their difficulty in concentrating on the question. People with autism may struggle to maintain eye contact or interrupt at inopportune moments, which again may give a poor impression to the observer. They may fixate on a topic and it can be difficult to move them away from that topic without exacerbating the person’s anxiety levels, thus causing distress and potentially causing a blockage in communication.

Support from ABE to trial

Effectively communicating with an individual with neurodevelopmental difficulties is key to fostering trust and confidence, and reducing distress. The means of communicating (for example visual; signs; gestures) will vary considerably depending on the individual’s aptitudes and preferences, and is dependent on accurately gauging the individual’s level of understanding. It may be prudent to engage a professional at this point to better enable an informed way forward. Body language and tone of voice will influence up to 70% of understanding, behaviour and ultimately response. It is therefore imperative to ascertain the best way to communicate from the very outset and the individual themselves may be the best person to advise on this.

During questioning, the individual may be keen to please and may inadvertently be led in their response. This is especially true in the case of younger witnesses (or adults functioning at a young mental age) who will often effectively screen for what they believe to be the answer the questioner is seeking. When there is a breakdown in communication because the individual does not understand or becomes confused, challenging behaviour may occur. Their level of understanding may appear better than it is, as they learn to follow the cues of others, and some individuals may have deficits in understanding but strengths in their speech, meaning that they can appear better-equipped than they in fact are.

Reducing the complexity of sentences, along with visual cues or visual choices, may enable better understanding: it is often helpful that the use of abstract language and terms is avoided.

For the majority, the use of a registered intermediary (often with a background in speech and language therapy) will be important, as will special measures in the courtroom (for instance those laid out for children in the practice directions in this area), but it is important to recognise the limits of what these adaptations can meaningfully achieve.  Many will respond better to a one-to-one situation; being presented with a sea of faces may be very distressing and this will often mean that evidence using a video link will be the appropriate way forward, and a more effective way of obtaining authentic statements. Frequent breaks are also important – individuals with autism can often feel exhausted at the end of a school/work day due to the effort of having to screen for the normal response to social interactions and essentially mimic that of individuals without these challenges.

Whilst it may be normal to use rhetorical questioning, to suggest outcomes of situations, this will often not be a good strategy for those with autism and Asperger’s syndrome. Communications may be taken literally and it is therefore necessary to say less, rather than to try to explain a concept using analogy/metaphor, and to use and emphasise specific key words.  Pause between words and phrases to give time for processing. Ask only the most necessary questions and certainly avoid using irony, sarcasm or exaggeration. In addition, individuals with neurodevelopmental disorders may have great difficulty in reading social cues, whilst their facial expressions may also be hard to read. Emotion may be very difficult for individuals with neurodevelopmental disorders to express and they may come across as uncaring and cold. Their tone and approach may be very practical and they may appear somewhat calculating and uninterested.

Some people with autism may use a style of communication known as echolalia. This would be very difficult to manage within a questioning situation as they will often repeat what is said because they have not understood the question or how to respond – they may also repeat words they do not understand, or use new words that they have created. As with individuals with learning disabilities, it would be sensible to have a communication assessment completed beforehand, to ascertain the appropriate method of communication and foresee any stumbling blocks which may occur.

Individuals with ADHD may have significant communication problems which can be exacerbated within a stressful environment or situation. It is vital to understand, to some extent, their processes and try to physically and practically minimise the impact of the stressful situation and the environment. Some of the issues will be around –

Saying things that they do not mean;

Talking too little / too much;

Not being able to follow a conversation;

Feeling overwhelmed and getting distracted;

Interrupting at inopportune times;

Failing to remain in one place for a requisite period.

The individual will hopefully have an understanding of how their communication is affected and already have some strategies in place. Individuals may struggle to cope with multiple stimuli simultaneously and may not be able to filter out that which is extraneous – for this reason they may essentially get overloaded and shut down in the face of this kind of stress, though they may also have devised other strategies to close out excess stimulus, such as shouting, walking out of the area, or covering their ears or eyes.

It is important to have an understanding of what works for each individual. Whilst under pressure, the person with a neurodevelopmental disorder may be inclined to say whatever comes to mind as they frantically search for the right phrase or idea. A stressful situation such as this may result in them being unable to speak, or alternatively talking endlessly. They may also be distracted by random noises or other conversations taking place around them. There may be interim physical adaptations which could be made within the court environment to reduce these distractions.

Potential actions

Seek specialist advice and if required instruct an expert witness – the expert witness may be able to set out the elements of challenge that the jury could usefully bear in mind when hearing from/seeing the witness

Instruct a registered intermediary if required

Ensure that the court setting takes into account the individual’s specific needs (environment; language used; procedures)

Seek advice and information from those involved in providing treatment, particularly around communication and medication

Instruct a suitably-qualified forensic psychologist or psychiatrist if the defence seeks to use the condition as a means to attack the credibility of the evidence

Mental Health Conditions - Schizophrenia and other psychotic disorders

Introduction

There are a range of conditions which can cause psychosis.  Psychosis describes a state of mind in which people hear, see, feel or believe things that do not exist, or are not real, and have difficulty distinguishing between their internal and the external world. Common examples include hearing voices or believing that people are trying to do them harm. People can experience psychosis for a wide variety of reasons; for example, psychosis can be due to having a mental illness such as schizophrenia or bipolar affective disorder, or may be caused by drug use, brain injury or extreme stress. There is no one single cause of psychosis but researchers believe that genes, biological factors and environment may play a part. Some people might experience psychosis only once, or have short repeated episodes throughout their lives. Others will experience psychosis on a daily basis and will need a high degree of support to manage the symptoms.

Diagnoses

Schizophrenia

Schizotypal disorder

Delusional disorders

Acute and transient psychotic disorders (brief psychotic disorder)

Schizoaffective disorder

Schizophreniform disorder

In addition, psychosis can be drug induced, or induced by a physical condition or extreme stress.

Presentation and symptoms

Psychosis is used to describe conditions that affect the mind, where there has been some loss of contact with reality. When someone becomes ill in this way it is called a psychotic episode. During a period of psychosis, the individual may present with distortions of thinking and perception, and this may be accompanied by emotions that are inappropriate or blunted. Schizophrenia is a mental illness characterized by periods of psychosis.

The most common types of psychotic symptoms are delusions and hallucinations. Delusions are firmly held beliefs that no one else shares. When psychotic, people continue to hold the belief even when challenged, or shown evidence that the belief can't be true. Hallucinations include seeing things that other people do not, experiencing tastes, smells and sensations that have no physical cause, and hearing voices that other people cannot hear. Delusions and hallucinations can make people feel anxious, scared, afraid or confused.

Paranoid delusions can make it hard for people to trust other people or organisations. Alongside these feelings, people may have distorted thoughts, with a sense of being controlled by ‘outside forces’. Feelings of paranoia may result in odd behaviour or stupor, with blunted, flat emotional responses or expression. People with schizophrenia may also have disturbances with thinking and concentration, have difficulty in managing social interaction, work or study, and may be unable to manage daily activities.

Schizophrenia may be acute or chronic; some people will experience one episode, respond well to treatment, and experience very little disruption to their lives. Others may experience ongoing fluctuations in their symptoms with phases of illness and recovery. Some will experience chronic psychotic symptoms that are unresponsive to treatment. Those with chronic schizophrenia often present with symptoms such as social withdrawal, difficulty in expressing emotions, and difficulty in taking care of themselves.

For those with schizoaffective disorder, in addition to psychotic symptoms there will be a significant mood element to their presentation with both being prominent in the same episode of illness. They may present with either high (manic), or low (depressed) mood. Manic people present as excitable and talkative, and are often difficult to interrupt. They may make unrealistic plans, have poor sleep, demonstrate excessive spending and may engage in risky sexual encounters.  Mania is sometimes called bipolar disorder if paired with depression. Depressive symptoms include lack of sleep, a feeling of emptiness and hopelessness, despair, suicidal thinking, poor concentration and loss of appetite.

Delusional disorder is characterised by a single delusion or set of related delusions. Hallucinations are not typical and there is usually no disturbance in mood, speech or behaviour.

Treatments and their implications for trial

Effective treatment for an acute psychotic episode includes ensuring safety, reducing the symptoms of psychosis and disturbed behaviour, building a therapeutic relationship, and developing a management plan to aid recovery. In an acute episode of psychosis antipsychotic medication is often an essential starting point for treatment. Individuals with more chronic conditions may also receive a cognitive behavioural therapy, community support and education.

Antipsychotic medication is generally an effective method for decreasing psychotic symptoms such as agitation, delusions and hallucinations. Most antipsychotic medication has significant side-effects, which need to be understood in the context of interview and trial. Many of these medications are sedative in nature, which may impact on the individual's ability to give evidence. Simple solutions maybe available; for example treating clinicians could alter the timing of medication so that such sedation can be minimised at crucial times of the day. It will be essential for acute psychosis to be treated if the individual’s evidence is to be of value. In these cases, a thorough psychiatric assessment will be required as it is likely that such a complainant will be deemed unfit to give evidence whilst they remain floridly psychotic.

Antipsychotic treatment will also be a factor for those who are prescribed long-term antipsychotics – these medications may be prescribed to prevent relapse as well as to treat the immediate antipsychotic crisis. Those with a chronic condition may also, separately, have difficulty attending to and processing information, which will need to be understood if they are to give effective evidence.

Potential implications

Sexual assault may precipitate relapse in a previously stable individual. Those with a history of psychosis, particularly if that involves paranoid thinking, maybe particularly sensitive to perceived challenge or criticism; they may present as guarded or aggressive in nature.

It will be essential to liaise with relevant services early in the process. Complainants may have difficulty in processing information in unfamiliar and stressful environments. Assistance from health professionals will be needed to assess current mental state, assess risks, and determine the appropriate treatment. Any acute symptoms must be actively treated, as these may interfere with the ability to give evidence.  Complainants with a history of psychosis should be considered to be vulnerable witnesses who will need greater consideration in providing support and preparation – both emotional and practical - to help them give the best evidence. It will be essential for services to work with individuals to ensure that they have the necessary coping strategies to help them regulate their emotions. Contingency/crisis management plans should be shared, to ensure that all are clear what needs to happen if a complainant can no longer cope.

Support from ABE to trial

Understanding how the individual’s condition affects them is crucial and requires significant pre-planning before engagement in interviews or in giving evidence. The stage of treatment should be understood, if necessary with the assistance of mental health professionals. It is likely that the individual may require an intermediary, to maximise the quality of their evidence. Treating mental health professionals can also assist in the planning of the interview – providing advice on how questions should be asked, the need for regular breaks, time of day, being mindful of effects of medications etc.

In regard to communication during interview and trial, there are some basic approaches that may reduce the anxiety of the individual.

Demonstrate a non-threatening posture with a calm and quiet tone, awareness of interpersonal space.

Keep statements short and give one message at a time. Too many choices at once may confuse.

Accept and acknowledge that this is their reality – therefore, adopt a non-argumentative approach, avoid aggression and provide only incremental low-scale challenges where possible. Give reassurance.

Trauma and distress can interfere with the process of remembering and this needs to be considered and accommodated.

It is common for individuals in this group to be disbelieved – to have their experience viewed as a symptom of their psychosis. If the individual is currently receiving treatment, it is important that this continue. Immediate and effective treatment should not be viewed as interfering with or tainting evidence, as it will be necessary if the individual is to give evidence.

Potential actions

There will need to be active liaison with mental health services, and/or the individual’s GP.

As it is highly likely that the individual will be receiving psychotropic medication, expert input should be obtained from a psychiatrist, rather than a psychologist.  They will in all likelihood want to review the medical records, so these should be obtained in advance.

A registered intermediary should be considered.

Mental Health Conditions - Affective disorders

Introduction

Affective disorders are those disorders that affect mood, and include both elevated (mania, hypomania) and depressed mood. Whilst these disorders can be disruptive, there are effective treatments available, including both medication and psychotherapy. Some people only experience one or the other, whilst some cycle between low and high mood states. Both states can be associated with psychosis, in their most severe forms. The term bipolar affective disorder is used to describe disorders where these are repeated episodes of mood abnormality, both in terms of elevation of and lowering of mood, occurring at different times. Characteristically recovery is usually complete between episodes. Dysthymic and cyclothymic disorders are less severe forms of mood disorders, although still distressing, and characteristically persistent.

Diagnoses

Mania and hypomania

Depressive disorder (major depressive episode, depression)

Bipolar affective disorder (type I and type II, manic depression

Cyclothymic disorder

Persistent mood disorders (cyclothymia/ dysthymia)

Presentation and symptoms

There are a number of similarities in the presentation and symptoms of an individual within this group, although the severity of symptoms will vary greatly, as will the duration. The commonalities within the depressive disorders include significantly lowered mood and diminished interest or pleasure in activities.  Depressed mood is common, but major depression can be distinguished from this normal low mood by its severity, persistence, duration and the presence of the other characteristic symptoms commonly described, as below:

Loss of energy or fatigue

Loss of confidence and self esteem

Diminished ability to concentrate or make decisions

Excessive or disrupted sleep

Alterations in appetite with associated weight change

Feelings of guilt and worthlessness

Decreased libido.

The depressed mood is relatively constant from day to day, although may fluctuate over the course of a day, with the general pattern being that the mood improves as the day progresses.

Dysthymia is a milder but more persistent (over a number of years) mood disorder, and is never associated with psychosis.

Bipolar affective disorder is a cyclic disorder characterised by both mania and depression. The most common presentation involves repeated episodes of either presentation separated by periods of remission.

Mania can also be diagnosed independently of bipolar disorder, although this is unusual. Symptoms of mania include:

Elevated mood (sometimes with irritability)

Increased energy and activity

Rapid pressured speech with flight of ideas

Impaired concentration and attention

Enhanced libido often leading to disinhibition and inappropriate sexual activity

Impaired judgement and impulsive behaviour

Decreased need to sleep

Grandiose ideas and inflated self-esteem.

Hypomania is a mood state characterized by persistent disinhibition and euphoria, though is less severe and persistent than mania.

Cyclothymic disorder is thought of as a mild form of bipolar disorder. There may be low grade elated periods (hypomanias) as well as brief fleeting periods of depression. These may have a short span of less than 2 weeks at a time. However, if there is little respite between episodes, in some cases, this may progress to full blown bipolar disorder.

Treatments and their implications for trial

There are two main treatments for affective disorders: medication and therapy. Effective treatment usually involves both. There are many different antidepressants available for the treatment of depression, which can relieve the symptoms, though these tend to have a number of side effects. They may cause restlessness, loss of appetite, loss of libido or dry mouth amongst other physical responses. Whilst these medications can be effective at relieving a number of symptoms, they may not be curative and where the low mood is exacerbated by trauma the victim may still experience flashbacks and nightmares associated with it, even if their mood improves.

For bipolar affective disorder and its variants, mood stabilisers can be used which essentially work to achieve a more even mood without the swings and associated unpleasant symptoms. Again, these medications are rarely curative and the subject may experience periods of low and high mood at times, though hopefully not to the same degree as when unmedicated. Side-effects that may interfere with the giving of evidence can include tiredness, tremor, nausea and diarrhoea. In individuals with a history of both depression and mania, treatment with antidepressants can precipitate a manic episode.

Individuals with more serious mood disorders, which can include psychotic symptoms, may also receive treatment with antipsychotic medication which can have significant side effects, including profound sedation.

Psychotherapy is also an important part of treatment. It can help the individual to learn to cope with the disorder and help change the behaviour that contributes to it.

Hypnotherapy is gaining wider recognition as a treatment for depression. Hypnoanalysis seeks to uncover the root causes of the negative thoughts and emotions. It also seeks to develop better coping strategies. However, the hypnotherapist ‘connects’ directly with the subconscious mind and may address the individual’s perception of events. When delivered properly, this form of treatment can be extremely effective but if used improperly it could produce false memories, or lead to memories becoming distorted and essentially false, although the individual will believe it to be true. Such risks can also be applied to other types of psychotherapy, where therapists are seeking to uncover repressed memories which may account for the symptoms presented. It is noteworthy that, on the whole, such therapies are not delivered by the NHS.

Mood disorders, if untreated will present challenges, in that bipolar affective disorder can cause unexpected and dramatic changes in mood, irritability and unpredictability. . Individuals can get easily annoyed or aggravated by people who are trying to help them. It is worth being aware of this in a court setting, as if the questioner becomes persistent, the complainant may anger easily. Depressed individuals may present as somewhat uncooperative or lacking in emotion; such a presentation may be misinterpreted by a jury.

For individuals with mood disorders then contingency and crisis plans can be extremely helpful. These will document known triggers that can precipitate deterioration, and also outline effective coping strategies. This information will be of use when considering how an individual can be facilitated to give their best evidence.

Potential implications

Depression and anxiety associated with sexual assault may lead to insomnia, eating disturbance, feelings of guilt and shame, anger, self-harm and suicidal thinking.  These disorders have serious implications and appropriate support must be arranged for a complainant if they are to participate in the trial process.  Complainants may also experience an increase in somatic complaints such as headaches, muscle tension and stomach upsets, and research has demonstrated that rape survivors visit their doctors more frequently for such complaints.  They may be prescribed sedative medication by well-meaning general practitioners, however clearly such medication may interfere with their ability to give evidence effectively. Mood changes can result in withdrawal behaviour which may be misinterpreted by jurors, or the appearance of not taking the proceedings seriously or not experiencing serious consequences from the assault. Anxiety may lead the victim to avoid court and to ask not to take matters further when given the opportunity.

Support from ABE to trial

The risks presented by someone with a serious mood disorder must be borne in mind.  Victims of rape are more likely to hurt themselves and to commit suicide than matched controls. It will be essential to ensure that appropriate services involved in providing care for the complainant with are pre-existing or newly developed mood disorder.

It is vital to understand the stage of treatment and to encourage liaison and compliance with relevant GP and mental health services. Individuals should generally be encouraged to disclose what has happened to them to those providing care, if they have not already done so. It may be extremely difficult to achieve best evidence interviews with someone who is experiencing mania.

It will assist the individual if their feelings are recognised and acknowledged. They are real and important to them. People with affective disorders do better when they have the support of family, carers or a trusted individual. It may be prudent to identify these people before the process commences.

As with other mental disorders, affective disorders are often of chronic duration meaning that the individual may still be symptomatic during the trial, even with treatment. Specific adaptations may be needed – to reduce their anxiety. Special measures should be actively considered and facilitated. Consideration must be given to the impact of medication, and the mental disorder, when scheduling court appearances. In general terms regular breaks are likely to be of benefit given that concentration is often significantly impaired.

Potential actions

There will need to be active liaison with mental health services, and/or the individual’s GP.

As it is highly likely that the individual will be receiving psychotropic medication, expert input should be obtained from a psychiatrist, rather than a psychologist.  They will in all likelihood want to review the medical records, so these should be obtained in advance.

A registered intermediary should be considered.

Mental Health Conditions - Anxiety, stress-related and somatoform disorders

Introduction

Anxiety disorders may cause people a number of different physical and psychological problems. The psychological symptoms of anxiety include feelings of dread and irritability, increased muscle tension and enhanced activity of the nervous system. This leads to a variety of physical symptoms such as dry mouth, shortness of breath, dizziness and trembling. Anyone can have feelings of anxiety. These may occur in response to a stressful situation. Sometimes these feelings can be helpful, for example, by increasing a person’s ability to perform in a race. These feelings are normal. Only when the symptoms are more intense or long-lasting do they interfere with a person’s concentration and ability to do routine tasks. People may avoid situations that could provoke feelings of anxiety. This interference with daily living, as much as the symptoms themselves, may lead a person to seek help.

Diagnoses

Phobias including agoraphobia, social phobia

Panic disorder (panic attacks)

Generalised anxiety disorder

Obsessive compulsive disorder (also known as OCD)

Individuals may also present with disorders relating to a specific stressor.

Acute stress reaction

Adjustment disorder

Post-traumatic stress disorder (also known as PTSD, complex PTSD, Type I and Type II trauma)

Or may experience physical (somatic) complaints as a result of specific and recurring fears about their health.

Hypochondriacal disorder

Somatisation disorder

In addition, there are a group of disorders characterised by dissociation.

Dissociative disorders (also known as dissociative identity disorder, DID, multiple personality disorder)

Presentation and symptoms

Some people suffer from anxiety all of the time – this is called generalised anxiety. For people suffering from panic attacks, the symptoms of anxiety are likely to come out of the blue. Another sort of anxiety disorder is called a phobia, in which people have problems in certain situations – ordinarily this would be described as an overwhelming fear of a certain type of stimulus – it could be a fear of spiders, air travel or visits to the doctor. With a clinical phobia, the reaction goes beyond simple aversion and can manifest as panic, sweating, dizziness, nausea and feelings of loss of control, and sometimes fainting spells. With individuals who have experienced sexual trauma, phobias may take the form of social fears or fears of leaving the house. The social fears may be limited to a specific situation or may be associated with any social situation; agoraphobia describes a fear of leaving the house with a sense of unease and an expectation of catastrophe if the individual does leave.

Obsessive compulsive disorder is characterized by two components – an obsession, which is a recurring resisted thought related to some aspect of living (for example about germs, or potential catastrophic events) and a compulsion, which is a powerful drive to act on the thought and repeat some form of behaviour to excess – with hand-washing, this can result in skin abrasions and pain, as well as the interference with normal life – individuals often report being late for work as a result of the need to engage in protracted rituals. Obsessive compulsive disorder is normally associated with a fear of the consequences of not carrying out the ritual, which may include a general sense of impending doom or specific worries about family members being hurt in some way, or otherwise unlinked disasters befalling them.

Hypochondriacal disorder is a fear of having a physical illness and the attribution of various physical states to a condition of serious ill-health, often maintained even in the face of normal physical examination and investigations. The individual may insist that they are unwell despite reassurance from doctors and nurses, and will sometimes seek second, third and fourth opinions due to their conviction that they are physically ill and in all likelihood dying. In trauma victims, hypochondriasis may represent an unresolved anxiety linked to the trauma and it may also be associated with low mood. Somatisation disorder is a similar condition in which the individual translates mental distress into a physical manifestation in the body, again without medical origin. In victims of assault it may represent an inability to directly process the psychological trauma, which is expressed in physical ways instead.

Dissociative disorders remain controversial in respect of dissociative identity disorder (multiple personality disorder), which is much more frequently diagnosed in America, Dissociation of a body part is, however, a recognised phenomenon and may occur again under conditions of extreme distress, with the subject feeling that part of their body no longer belongs to them. Similarly, this is associated with other mental disorders such as mood difficulties.

Post-traumatic stress disorder is another form of severe anxiety, and it is this disorder which is potentially of particular relevance for this toolkit.

PTSD is a condition that develops following exposure to traumatic incidents. Many people feel grief-stricken, depressed, anxious, guilty and angry after a traumatic experience. The condition is characterised by re-experiencing (reliving the trauma), avoidance, alterations in cognitions and mood, and hyperarousal.

Individuals find themselves reliving the event, again and again, either with flashbacks, or nightmares.  With re-experiencing, the symptoms can be so realistic that individuals act or feel as if a traumatic event were recurring, and they can cut off from reality (dissociation). People can feel both the emotions and physical sensations of what occurred, and many ordinary events can trigger flashbacks. For instance, if someone was raped by a man with a beard, seeing a different man with a beard might start a flashback. People will often want to avoid thinking and feeling about the trauma, so they will distract themselves and avoid anything that reminds them of what happened. They will also avoid talking about it, and may forget important aspects of what went on.  People  may deal with the pain of their feelings by trying to feel nothing at all – by becoming emotionally numb. They may communicate less with other people, and find that they are unable to have loving feelings and connect with others in the same way. People can seem quite detached and cut off. Individuals may find however that they stay ‘on guard’ all the time, watching out for danger. They find it hard to relax, to sleep, and to stay calm. They may be angry, irritable and jumpy.

Many people with PTSD also drink excessive amounts of alcohol, take sedative types of drugs and experience depression, headaches, muscle aches and pains and other physical symptoms.

Early onset abuse or partially severe and sustained traumatic experiences can lead to a more severe, pervasive condition known as complex PTSD, although this does not appear in diagnostic classifications. The revised PTSD criteria in DSM 5 cover some of the symptoms seen, but not all. They are not included in ICD 10 and in the UK these disorders may be better described as mixed disorders of conduct and emotions (in children) or by one of the forms of personality disorder in adults, and can include self-injurious behaviour, hopelessness, worthlessness, low self-esteem, poor coping mechanisms, chronic suicidal ideas and difficulties in establishing stable relationships.

Trauma can seriously affect a child's development – and often the earlier the trauma, the more harm it does. Some children cope by being defensive or aggressive. Others cut themselves off from what is going on around them, and grow up with a sense of shame and guilt rather than feeling confident and positive about themselves. Children will often develop the psychologically defensive mechanism of dissociation, or cutting off from reality. This may then re-emerge later in life, sometimes at times of subsequent trauma. Such individuals may then present quite differently to those with ‘classic’ PTSD but the element of reliving the trauma can endure.

Adults who have been abused or tortured over a period of time develop a sense of separation from others, and a lack of trust in the world and other people.

Treatments and their implications for trial

Memory can be affected by some of the newer pharmacological treatments used for PTSD, which can have an impact upon victims during the prosecution stage.  Whilst the usual recommended pharmacological treatment for PTSD is antidepressant medication, there are other classes of drugs which are being explored. (Chandler, J.A. Mogyoros, A. Rubio, T.M. Racine, E. (2013) Another look at the Legal and Ethical Consequences of Pharmacological Memory Dampening: The Case of Sexual Assault.  Human Right and Disability. Winter 2013). One of the etiological theories for PTSD is that the traumatic experience leads to the overstimulation of stress hormones, which enforce conditioned fear responses to stimuli which are frightening. (Ibid).

Drugs which block the conditioning effect of stress hormones, such as beta-adrenergic blockers, have therefore been explored as a potential way to prevent the development of PTSD.  Research indicates that the effects of the beta-adrenergic blocker, propranolol, or ‘what has come to be called memory dampening treatment’ and report on several studies which have found promising results in treating established PTSD by using propranolol to disrupt the reconsolidation of traumatic memories. There are clearly ethico-legal issues that this treatment raises and particularly a potential impact upon the victim’s testimony ‘given recently published results suggesting that this treatment may affect factual recall of a traumatic event as well as the emotional qualities of the memory’. An individual’s credibility might be adversely affected if their memory and emotional response to the traumatic memory are dampened. (Ibid). Researchers in the aforementioned study suggest the need for ‘general ethical analyses to be tested in specific cases before general conclusions are made about the ethical appropriateness of novel treatments for PTSD’.

Potential implications

PTSD can be an extremely distressing and disabling condition. Intrusive symptoms such as flashbacks, nightmares and feeling as though the assault is reoccurring are profoundly distressing to individuals who experience them. Their psychological response is often to become avoidant of thoughts, feelings, places and other reminders of the assault. This in turn will mean that individuals with PTSD may not want to talk about what has happened to them; they may also forget important aspects of the events in question. Some individuals present with significant levels of numbing and detachment, a presentation which can lead those observing them to believe that they are not at all distressed, when in fact these symptoms are characteristic of PTSD. PTSD sufferers may also experience increased levels of arousal with difficulty sleeping, poor concentration, anger and irritability, jumpiness and an exaggerated startle response. As a result of these symptoms many with PTSD (up to 30 per cent) will utilise drugs or alcohol in order to cope with the unpleasant feelings; characteristically depressant drugs such as alcohol, marijuana or prescribed benzodiazepines are used. The difficulties experienced by complainants with PTSD should be understood, so that their presentation is contextualised. It should also be remembered that some individuals will have significant post-traumatic responses without the threshold for a formal diagnosis being reached, although they may still be profoundly affected by these symptoms.

Support from ABE to trial

Requiring the complainant, especially if they have developed PTSD, to confront their traumatic history during interviews and courtroom testimonies thwarts characteristic efforts at avoidance and predictably results in the resurgence of intrusive ideation and increased arousal. The wish to avoid such distress may lead individuals to avoid court by retracting or altering their account, or not disclosing the full extent of their experiences. On the other hand, it may only be during times of high arousal that the complainant is able to access the traumatic memories in detail. It is therefore important that a balance is struck, that they are given the time and support that is needed in order to give an account and that reactions in court are dealt with appropriately.

The nature of the court process pits the complainant against the defendant, whom the survivor already sees as a fearsome enemy. They will then be faced with counsel for the defendant, who is likely to attempt to discredit their experience and to try to persuade the jury that they are not to be believed and that their testimony is corrupt. The defence may also attempt to shift responsibility on to the complainant and blame him or her for their client’s conduct. People often complain that it is they who feel as though they are on trial and that they, unlike the accused, are merely a witness and as such are not assigned counsel. It could be argued that the rape prosecutor acts as that counsel, but the complainant will only believe this if that prosecutor looks at their case positively, engages the complainant sympathetically before the trial, and starts with a belief in them and their account. Corroboration must be actively sought and inconsistencies or lies must be dealt with rather than wished away. An informed prosecutor, who offers respect to the complainant and who understands the issues outlined in this toolkit, is far more likely to secure the best evidence possible from the complainant who is, after all, a key witness.

If the case proceeds, the trial will often take place while the complainant is still experiencing psychological symptoms. Research has shown that under ordinary conditions people with PTSD often have fairly good psychosocial adjustment; however, they do not respond to stress in the same way that other people do. Under pressure (such as at interview, or in court) they may act or feel as if they were being traumatised all over again. This high state of arousal may facilitate memory retrieval and therefore should not necessarily be avoided, although significant explanation and support will be needed. During the attack the survivor was overpowered and helpless. They need to feel that they have control over their life again. Individuals can be helped if they are allowed to make decisions, where possible. Simple techniques such as enabling them to decide if they need a break during testimony can be helpful. This will not only empower them, but will also prevent the compassionate judge rising just at the point when arousal is positively impacting on accessing memories.

For those with PTSD then, the use of special measures will generally assist the complainant in giving their best evidence. Again, individuals should be consulted about what will help them. For some, screens will suffice; however for others the use of the video link will be of far greater benefit.

Potential actions

Empower the complainant by allowing them to make decisions where possible (such as when to take a break).

Utilise all special measures that may be available. Consult the complainant.

Consider the evidential value of a diagnosis of PTSD, and the possible use of expert testimony as per R v Adam Eden R [2011] EWCA Crim 1690.

Mental Health Conditions - Substance use disorders

Introduction

Individuals who become complainants may have pre-existing substance use disorders or may begin to abuse substances as a result of their experience of trauma. Frequently, individuals may have a problem with several substances. Prosecutors need to be aware of the potential for abuse of alcohol, prescribed and illicit drugs. Up to 30% of victims of sexual assault will start to abuse substances following the assault. The use of depressant substances is often seen, as individuals will use these to self-medicating and to reduce symptoms of anxiety and hyper arousal.

There is a wide spectrum of use and misuse of psychoactive substances. When it becomes a problem to the individual, substance use is generally characterized by:

A strong and sometimes overpowering desire to take the substance

Difficulties in controlling use

Problems associated with use.

Diagnoses

Diagnosis focuses on either harmful use, when an individual has a pattern of substance use that is causing damage to either their mental or physical health, or dependence. Dependence is a psychological syndrome which occurs after repetitive use of a substance typically for months or years. The diagnosis of dependence should only be made if three or more of the following have been experienced sometime during the previous year:

A strong desire to take the substance;

Difficulties in controlling the use of the substance;

A withdrawal syndrome when the substance use has ceased or been reduced;

Evidence of tolerance such that higher doses are required to achieve the same effect;

Neglect of interests and increased amount of time taken to obtain the substance or to recover from its effects;

Persistence with the substance use despite evidence of its harmful consequences.

Presentation and symptoms

Presentation will vary greatly from individual to individual, and will also depend on the substance which they are abusing, and the severity of their dependence. They may, at the time of report or interview, be intoxicated or in a state of withdrawal. This will profoundly affect their presentation and behaviour and can have an impact on their ability to give testimony.

Individuals who are substance dependent prior to the traumatic event may be disbelieved, and they may deteriorate rapidly following an assault, even if they had previously been abstinent. It is worth noting that traumatised individuals will often use substances to block out unpleasant and painful emotions, as can arise following sexual assault, as a form of self-medication. Deterioration may follow a sexual assault, or, individuals may develop problems for the first time.

Issues relating to withdrawal as well as intoxication are of relevance. Withdrawal states are a group of symptoms of variable clustering and severity and occur on absolute or relative withdrawal of the substance. Onset and course of the withdrawal state are time-limited and related to the type of substance and the dose being used immediately before abstinence.  Alcohol withdrawal can lead to tremors, convulsions, or uncontrolled shaking of the hands (or even the entire body), profuse sweating, even in cold conditions, extreme agitation or anxiety, insomnia, nausea or vomiting, seizures and hallucinations. In some cases it can be lethal or lead to permanent brain damage.

Treatments and their implications for trial

The mainstay of treatment for individuals dependant on substances is to reduce harmful use, and to maintain that change. For some, this will involve total withdrawal from use, whilst for others this will involve substance replacement (e.g. the introduction of methadone in place of heroin).

Potential implications

Where someone has a serious, life-threatening dependence there may be issues with attending court and giving evidence. It is likely that they will either be intoxicated, or if not, will be in a state of withdrawal, and therefore, depending on the nature of their addiction, at grave risk unless under medical supervision, at the time of any trial. By way of example, alcohol detoxification poses a significant risk to the dependent individual.  A sudden discontinuation of alcohol consumption can often induce a condition known as delirium tremens, and individuals can die as a direct result of alcohol withdrawal, usually from severe seizures; brain damage can also result from B vitamin deficiency. Even if an individual has managed to achieve abstinence, then continuing abstinence could not be guaranteed by the time the matter reaches court.

Support from ABE to trial

Substance-dependent individuals will need significant support from services, and an awareness and understanding of potential issues from both the police and prosecutors. Special measures may be of assistance, particularly the opportunity to give evidence remotely, at a time prior to the trial starting, that time to be determined by abstinence/less harmful use, following a withdrawal period. It may be profoundly problematic for an individual to give evidence safely and effectively in person, on a fixed date. Indeed, requiring them to do so could pose a significant threat to life, if the individual attempts to withdraw himself or herself before the trial, without medical supervision.

Potential actions

Obtain specialist advice, depending on the nature of the addiction.

Maintain awareness of the possibility of intoxication at the time of trial, and the impact that this will have.

Consider the use of special measures.

Consider if evidence needs to be heard without the complainant’s presence being required.

Mental Health Conditions - Conduct and Personality disorders

Introduction

Personality disorders are conditions where there is an enduring pattern of inner experience and behaviour that deviates markedly from the normal expectations of the individual’s culture.  This pattern can be manifested in the areas of cognition, affectivity, interpersonal functioning, emotional responses and impulse control.  A personality disorder can affect how people cope with life, how they manage relationships, how they behave and how they feel. There is no single cause of personality disorder, and individuals can have both a personality disorder and another mental disorder. Generally speaking, personality disorders are enduring, with patterns that are inflexible and pervasive across a broad range of personal and social situations. They lead to clinically significant distress or impairment in social, occupational or other important areas of functioning.  The patterns are stable and of long duration and their onset can be traced back to at least adolescence or even early adulthood.

Diagnoses

Diagnoses can be separated into 3 clusters based on descriptive similarities:

Cluster A - People with cluster A personality disorders can find it hard to relate to other people. Their behaviour might seem odd or eccentric to other people. Diagnoses include paranoid personality disorder, schizoid personality disorder, and schizotypal personality disorder.

Cluster B – People with cluster B personality disorders can find it hard to control their emotions. Other people might see them as unpredictable. Diagnoses in this cluster are antisocial personality disorder (otherwise known as ASPD), borderline personality disorder (BPD or otherwise known as emotionally unstable personality, EUPD), histrionic personality disorder, and narcissistic personality disorder.

Cluster C – People with cluster C personality disorders have strong feelings of fear or anxiety. They might appear withdrawn to other people. Diagnoses in this cluster are dependent personality disorder, avoidant personality disorder, and obsessive-compulsive personality disorder.

Presentation and symptoms

Presentation and symptoms will differ depending on the personality disorder classification, and some people may have more than one diagnosis.

For example, an individual with a paranoid personality disorder may present as extremely inflexible, with a long-term pattern of social awkwardness. They may be socially withdrawn and may present with distorted thinking. They may often misinterpret the motives and actions of others as malevolent, with a long-standing suspiciousness and generalised mistrust of others. They are frequently incapable of overly involved relationships. Unlike a person with schizophrenia, they have no hallucinations or formal thought disorder.

Individuals with schizoid personality disorder may often come across as withdrawn or aloof which will significantly affect their ability to form positive relationships with others. However, they may have successful lives and hold down jobs effectively, though will often seek situations where they have little contact with others. They can be described as eccentric or “weird” due to their reluctance to engage in activities with others. Individuals with schizotypal personality disorder are marked by an acute discomfort with, and reduced capacity for close relationships as well as by cognitive or perceptual distortions.

There are also similarities in the cluster group including antisocial personality disorder, narcissistic personality disorder and borderline personality disorder. Whilst there may be a common element of dramatic, emotional or erratic behaviour, there are marked differences in presentations. A person with antisocial personality disorder tends to have a disregard for and the violation of rights of others. This may also be marked by an inability to conform to social norms.

Individuals with emotionally unstable personality disorder, alternatively know as borderline personality disorder, often report an early onset of neglect and trauma.  It seems that this type of trauma can produce a damaged personality with deficits in emotional regulation, demonstrated by fluctuating mood, self-harm, identity disturbance, self-damaging behaviour and impulsivity.  These individuals have a pervasive pattern of unstable interpersonal relationships, and poor self-image which can be further exacerbated by chronic feelings of emptiness. There are particular similarities with histrionic personality disorder with a pattern of excessive emotionality and support seeking. Those with narcissistic personality disorder have a pattern of grandiosity in both fantasy and behaviour. They have a need for admiration from others, though with a lack of empathy for others’ feelings. However, they tend to be less anxious than those with borderline personality disorder, living less chaotic lives and with a reduced risk of suicide.

Those with avoidant personality disorder show an extreme sensitivity to rejection and may lead socially withdrawn lives. They may appear shy and have a need for uncritical acceptance. Similarly those with dependent personality disorder may have an excessive need to be taken care of that can lead to submissive and clinging behaviour with a fear of separation.

Treatment and implications for trial

Personality disorders are serious conditions that can be associated with high risk behaviour, like self-harm. Risks may increase during stressful times, such as when participating in the trial process.

Support and treatment for people with personality disorder is limited; those usually most engaged with mental health services are individuals with borderline personality disorder (EUPD). Interestingly, in this group there appears to be a link with early onset experience of trauma, and there are broad similarities with complex PTSD, described elsewhere in this guidance. Treatment, where available, usually involves a course of psychological therapy, or psychotherapy. The aim of all psychological therapies is to improve people’s ability to regulate their thoughts and emotions. Some therapies focus on dysfunctional thoughts whilst others might focus on self-reflection. Group therapies in particular may help people understand social relationships better.

A range of different psychotherapies are used and are broadly classified into three types of therapy. Psychodynamic (reflective) therapy explores patterns of distorted thinking which are often related to negative early childhood experience. The goal is to understand how these distortions arose and find effective ways to overcome their influence on thinking and behaviour. This approach of treatment, either individual or group work, is particularly used with borderline personality disorder.

Cognitive behavioural therapy (CBT) is based on the theory that how we think about a situation affects how we act. In turn, actions can affect the way we think and feel. It is thus necessary to change both the act of thinking (cognition) and behaviour at the same time. A type of CBT called dialectical behaviour therapy (DBT) has proved successful in helping people reduce impulsive self-harming and is designed to help individuals cope better with emotional instability and to behave in a more positive way.

As several personality disorders may be associated with feeling of low self-esteem, anxiety and self-doubt, interpersonal therapy is sometimes used, based on the theory that relationships with other people and the outside world in general have a powerful effect on mental health.

No medication is currently licensed for the treatment of any personality disorders, however medication may be prescribed to treat associated symptoms, such as depression or anxiety. Some people with severe personality disorder, particularly BPD may be on a number of medications.

Personality disorder is often viewed in negative terms by the public, and as a weak defence in court settings. This disorder may have a stigma associated with it that goes beyond that of other mental disorders. This stigma may well have an effect during the legal process, with both professionals and the public (jury) having preconceived ideas, often influenced by high level media attention in the past where a single incident may have been reported. A study in New Zealand (Veysey, S. (2014) People with a borderline personality disorder diagnosis describe discriminatory experiences. Kotutui: New Zealand Journal of Social Sciences Online, 9:1, 20-35) reported that people with personality disorder often experience being characterised as being manipulative, difficult and attention seeking.

Potential implications

People with personality disorders may struggle to trust professionals and may be unable to maintain an even emotional state, so may be prone to outbursts, anger, tearfulness and impulsive comments. They may also find it difficult to maintain a demeanour which would impress upon the jury that they are taking the proceedings seriously, that they have respect for the process in the courtroom and that they have been traumatised. They may have long histories of contact with mental health services, and may be judged negatively as a result.  Some will have reported multiple trauma, and this may lead people to believe that they are fabricating accounts. If they have been repeatedly traumatised, then their emotional responses may be blunted. Alternatively, their distress may be manifested in feelings of anger towards others (not just the alleged perpetrator) and result in outbursts in court which could bring their good character into question. From the point of view of the legal team, they may find it that it takes longer to build the requisite trust with the individual and that they are overly suspicious of the motives of those trying to assist them.

Support from ABE to trial

Individuals may benefit from support from someone with a good understanding of their complex presentation. If available, care plans, contingency and crisis plans, utilised by the individuals and the services who support them may well offer significant insight. It is important to recognise and focus on the strengths that people have and connect with them by listening, showing respect and regard for their situation and the trauma they have experienced. Individuals have reported that there is, at times, an automatic disbelief from others about their experiences, once again derived from the stereotypical view of people with these disorders. The idea that making complaints is typical behaviour for someone with a personality disorder diagnosis can be a powerfully silencing one – with the individual drawing on past experiences of not being believed or listened to. Complaining can often be viewed as manipulative behaviour and this can have a negative effect on the persons willingness to proceed with their complaint.

When speaking with someone with a personality disorder directly, especially about sensitive issues, remember that emotional reactions may differ significantly from what might be expected. Ensuring an understanding of the disorder, and behaviour that may result, will be helpful.

Potential actions

Consider the need for support from the commencement of the interview process. Ask the complainant what would help them most.

Consider a familiarisation visit of the environment prior to the court appearance. Consider the use of written information material.

Ensure that the court setting considers the specific needs of the individual; the use of a registered intermediary may be of benefit, particularly in cases of severe levels of disorder.

Instruct a forensic psychologist or psychiatrist if the defence seeks to use the disorder as a means to attack the credibility of the evidence.

Specific considerations for children

Brain development continues into the early twenties (Blakemore, 2006  (Anderson V Anderson P Northam E Jacobs R Catroppa C. Development of executive functions through late childhood and adolescence in an Australian sample. (2001) Developmental Neuropsychology 20(1): 385-406); Sowell 2001 Sowell E Thompson P Tessner K Toga A. Mapping continued brain growth and gray matter density reduction in dorsal frontal cortex: inverse relationships during postadolescent brain maturation. (2001) Journal of Neuroscience 21: 8819–8829), with the frontal lobes of the brain playing a key part in various elements of cognition including judgement, consequential thinking, inhibition of impulses, empathy and coherent planning. It is important to recognise and account for this when asking children to give evidence as they may give unexpected answers as a result of their more limited capacities. Frontal lobe functioning increases over the course of adolescence (Anderson, 2001) (Ibid) - this has been linked with development of the brain’s prefrontal cortex (Blakemore, 2006) (Blakemore S-J Choudhury S. Development of the adolescent brain: implications for executive function and social cognition. (2006)Journal of Child Psychology and Psychiatry 47(3): 296–312), commensurate with an emerging ability to engage in consequential thinking (Steinberg, 2009) (Steinberg L. Adolescent development and juvenile justice. (2009) Annual Review of Clinical Psychology 5: 27-73). This development is not linear, meaning that individuals of the same chronological age may differ markedly in their capabilities.

As noted by the Royal Society in 2011 (The Royal Society. Neuroscience and the law: Brain Waves Module 4. (2011) Excellence in Science publications), the frontal lobes of the brain are the slowest areas to develop (Gogtay 2004) (Gogtay N. Dynamic mapping of human cortical development during childhood through early adulthood. (2004) Proceedings of the National Academy of Sciences 101: 8174-8179), in contrast with the amygdala (the part of the brain responsible for reward and emotion-processing). This imbalance is thought to account for increased arousal and risk-taking in adolescence (The Royal Society. Brain Waves Module 2: Neuroscience: implications for education and lifelong learning. (2011) Excellence in Science publications), alongside hormonal changes which may also act as specific neurodevelopmental triggers at certain stages. Adolescence represents a phase of increased impulsivity and sensation-seeking behaviour (van Leijenhorst 2010 (van Leijenhorst L Moor B Op de Macks Z Rombouts S Westenberg P Crone E. Adolescent risky decision-making: neurocognitive development of reward and control regions. (2010) Neuroimage 51(1): 345-55); Baird 2005 Baird A Fugelsang J Bennett C. ‘What were you thinking?’: An fMRI study of adolescent decision making. (2005) Poster presented at the annual meeting of the Cognitive Neuroscience Society, New York; Steinberg 2007 Steinberg L. Risk Taking in Adolescence: New Perspectives From Brain and Behavioral Science. (2007) Association for Psychological Science 16(2)), in tandem with a heightened vulnerability to peer influence (Steinberg 2007 Steinberg L Monahan K. Age differences in resistance to peer influence. (2007) Developmental Psychology 43(6): 1531-43), all of which have an impact upon decision-making.

It is important to factor in these elements when considering the plight of the child giving evidence in court, and it may be that the trial process would benefit from being nuanced in order to take into account these behavioural differences in comparison to adults.

The MacArthur Adjudicative Competence Study (Poythress N Hoge S Bonnie R Monahan J Eisenberg M. MacArthur Adjudicative Competence Study, MacArthur Foundation Research Network on Adolescent Development and Juvenile Justice) examined 927 youths and 446 adults in four locations across the United States, and found that trial competence related abilities tended to improve with age – eleven to thirteen-year-olds showed less understanding, less reasoning and less recognition than fourteen and fifteen-year-olds, who in turn performed significantly more poorly than sixteen and seventeen-year-olds (who functioned as well as adults). Low IQ scores were particularly associated with deficits. Young people were more likely to make choices in compliance with authority figures. Risk perception and future orientation deficits were found, and young people often did not understand their right to remain silent, and would see rights as being conditional. Research has also demonstrated that young people are more likely to make false confessions than adults (Redlich A Goodman G. Taking responsibility for an act not committed: The influence of age and suggestibility. (2003) Law and Human Behavior 27: 141-15).

Whilst the UK Crown Practice Directions issued by the Lord Chief Justice in 2000, and adjusted in 2013 and 2015, can go some way to facilitating the participation of the child, there are limits on their mitigatory effect and it cannot be assumed that any child can participate purely because court adaptations have been put in place. A young person’s deficits may not be immediately apparent and brain development is not always a smooth pathway. A child may, for example, show some strengths in some areas and be considered “streetwise” when it comes to drugs or violence, but this does not mean that they will have parallel aptitudes in other areas, for example decision-making about sexual matters.

Children are often terrified of the court process and may refuse on the basis that they are worried about being cross-examined by the accused, or that they would have to face them again in court. It is important that the child’s position is considered throughout as there are various stages to the process which will need to be explained. Visiting the courtroom in advance can be helpful for some children and they should have an opportunity to meet with the legal team in a non-confrontational setting in advance. The presence of developmental immaturity is one challenge; the addition of a mental disorder often serves only to heighten the young person’s vulnerability and fear, which again does not serve the interests of justice. Registered intermediaries can be helpful in advising about communication and interaction difficulties but ideally a child psychiatrist or psychologist would be enlisted where there is any doubt about the young person’s ability to give evidence, as it is crucial not just to assess for mental disorder but also to get an understanding of the young person’s strengths and weaknesses through a thorough formal assessment.

Recall, memory and diagnosis

Understanding the effects of fear and the psychological mechanisms that may occur during a sexual assault is vital when considering recall and memory. The first account given can be crucial, although the victim’s ability to give a clear account may be hampered, as there are a number of mental processes which might impact on the victim during the attack, namely de-realisation, de-personalisation, and dissociation. Terror, confusion, disorientation, helplessness and loss of physical control are also seen. These may prevent physical resistance or escape behaviour.  Survivors can lose track of what was going on, do things that they later realised they had not actively decided to do, experience a sense of altered time and also experience sensory disturbances.   These mechanisms may severely impair the person's ability to recall details of the assault and recall may change over time.  Memories of traumatic events are often organised on a perceptual rather than verbal level at least in the initial phase following the trauma.  Feelings and emotions can be recalled; however, a detailed narrative cannot be given.   With processing of the event (for example by talking it though with a friend, or support worker) more of the narrative component may become accessible, and the survivor’s account may change.

Many factors will affect an individual’s response to trauma. Studies point to the importance of the personal meaning of a trauma in accounting for post-traumatic adaptation.  Other elements that also contribute significantly to post-traumatic responses include perception of this threat, actual injury and being the victim of a completed, as opposed to an attempted rape.  In the early weeks and months following a sexual assault, most will experience extreme distress and disruption in many areas of their lives.  Research indicates that the majority then seem to recover from the acute effects of the attack at between 3 and 6 months; however, many will experience more prolonged distress, and a significant number will develop PTSD, as described elsewhere in this guidance.  One of the diagnostic criteria for this condition is the inability to recall important aspects of the events in question, and yet such incomplete memories can be used by the defence at trial, to suggest that the complainant is lying, or has developed false memories about what actually happened.  The defence may also use a complainant’s history of psychosis to suggest that the memories are false.

Difficulties with altered accounts and variable recall will be familiar, and once again, understanding the psychological processes behind these difficulties can only facilitate successful prosecution.  An inability to access the traumatic memories may make the giving of very detailed evidence in court impossible and the person may be erroneously seen as lying or incompetent.

Particular issues arise in relation to the reporting of historic cases.  Lay assumptions regarding traumatic experiences tend to assume that such incidents, as one of the most important experiences in life, would lead to an accurate and permanent memory being laid down.  It is also assumed that there should be consistency both in the central memory and in the peripheral detail and that the memory will never be forgotten. Trauma studies have indicated that these assumptions are incorrect. Trauma can lead to extremes of retention and forgetting.  Terrifying experiences may be remembered with extreme vividness, or may be totally inaccessible, and amnesia for all or part of a traumatic experience is not uncommon.  An individual may dissociate when faced with overwhelming emotion, and will then be unable to integrate the totality of their experience into conscious memory. This in turn will hamper the ability to provide a detailed, temporally accurate account.

It is also entirely feasible that long forgotten memories can be reactivated. The idea of repression of early traumatic memories is a concept that is well documented, although much debated. Such ‘recovered memories’ are often challenged as being false. When an adult recalls an incident of childhood sexual abuse after a delay of many years, sometimes under the influence of hypnosis or psychotherapy, this is, on occasions, referred to as ‘false memory syndrome’.

In relation to the false memory syndrome, or recovered memories, the Working Party of the British Psychological Society (BPS 1995 British Psychological Society (1995) Recovered Memories The Report of the Working Party of the British Psychological Society) indicated that:

Complete or partial memory loss is a frequently reported consequence of experiencing certain kinds of psychological traumas including childhood sexual abuse

Memories may be recovered within or independent of therapy

Recovered memories may contain significant errors, partly dependent on the age at which the event occurred

Sustained pressure or persuasion by an authority figure could lead to retrieval or elaboration of memories of events that never actually happened but there is no reliable evidence at present that this is a wide spread phenomenon.

It is entirely plausible that complainants recover memory from childhood after a period of stabilisation and withdrawal of, for example, illicit or prescribed medication.  This is not to say, however, that this memory was a false memory, i.e. one which was not based on events which had occurred.   A general population study by Elliot and Briere (Elliott, D. M., & Briere, J. Post-traumatic stress associated with delayed recall of sexual abuse: A general population study - Journal of Traumatic Stress  Vol 8, Nr 4 (1995)  (629-647)) showed that total amnesia for traumatic events occurred in a certain proportion of victims after every conceivable traumatic experience (except for witnessing the death of one’s child).  For some reason which is not entirely clear, sexual abuse during childhood leads to the highest degree of total amnesia, although this is also age related.

Memory is not perfect.  All of us are familiar with the experience of forgetting, but in addition to errors of omission (forgetting), we can make errors of commission, in other words we remember things that did not happen.  These false recollections can feel as real as any other memory and various experiments have been conducted which demonstrate that false memories can develop.  Generally, such errors occur when a range of memory ingredients, including experiences, things heard about, and things imagined are assembled into an inaccurate “pseudo” memory.  It is acknowledged that a child growing up in a stress-filled environment can develop techniques to ameliorate the impact of stressors, including mechanisms such as dissociating, i.e. cutting off from reality.  People who dissociate regularly are more susceptible to succumb to the suggestions for a pseudo memory. Whilst acknowledging this possibility in historic cases, it is just that, a possibility.

Conclusions

A number of mental disorders, and the condition of developmental immaturity inherent in all childhoods, are important considerations when thinking about the plight of the victim in court. Those subject to sexual assaults already represent a vulnerable group who have experienced trauma outwith what most people could countenance. The further ordeal of reliving and discussing in intimate detail the nature of the encounter would be intimidating for any person – when one adds in the challenges posed by mental disorder, developmental immaturity or both, it becomes clear that a high degree of support is going to be needed if the interests of justice are going to be properly served.

It is crucial that these vulnerable witnesses feel empowered to have their opportunity in court, and be able to see that society does not simply ignore sexual assault. Through careful consideration of the impact of sexual assault in the context of men and women with mental disorders, or those that are under 18, or both, we can move towards a sense of justice for the victims and their families. Individuals with mental illnesses, and children, can be valid and strong providers of key testimony to assist juries, but they may need greater levels of support than other witnesses. Expert witnesses can support legal teams to rebut speculation that the presence of a mental disorder and/or the presence of youth would unanimously render their refusal invalid, or their evidence dubious. The presence of a mental disorder does not automatically mean that an individual is incapable of making decisions about serious matters such as consent to sexual intercourse.

It is important that the factors of mental illnesses and developmental immaturity are given serious consideration by judges and juries in assessing the evidence put forward by these witnesses. It is also vital that any adaptations that would assist the victim to give evidence are considered and provided. Through better understanding of the nature of these challenges, it may be that more witnesses come forward and feel able to give their evidence in a safe and supported setting.

Contributors

Dr Enys Delmage is a Consultant in Adolescent Forensic Psychiatry and Honorary Assistant Professor at the University of Nottingham. He dual-trained in both Child and Adolescent Psychiatry and Forensic Psychiatry in West Yorkshire and has worked as a consultant at St. Andrew’s Healthcare from 2010 to 2017 – he left in November 2017 to work in New Zealand in an adolescent forensic inpatient service.

He has been a lecturer at both the Institute of Psychiatry and Nottingham University, and has, via a Master’s Degree in Law, developed a special interest in children and the law. He has provided court reports in criminal and civil settings and has also provided inreach to numerous young offender institutions, secure training centres and a secure children’s home throughout his career.

Prof Fiona Mason is a Consultant Forensic Psychiatrist and specialist in women’s mental health and the impact of trauma. She trained in General Psychiatry at the Royal Free Hospital, London, and went on to specialise in Forensic Psychiatry working as a Senior Registrar at the Maudsley Hospital, subsequently becoming a Lecturer in Victimology and Forensic Psychiatry at the Institute of Psychiatry. Between 1996 and 2001 she worked as a Consultant Forensic Psychiatrist at Broadmoor Hospital, where she was responsible for treating women with complex psychopathology and a history of traumatisation. Dr Mason joined St Andrew’s Healthcare in 2001 to develop services for women, working as a Consultant and then Lead for Women’s Services until 2010. She was then appointed as Deputy Medical Director in 2009, Director of Healthcare in 2011 and Chief Medical Officer in 2012. She left the organisation in 2016 to establish her own company.

She is a recognised leader in the field of women’s mental health and healthcare management and has published  and taught widely on the psychological effects of trauma and sexual assault, medical management and effective therapeutic practice.  As a Forensic Psychiatrist, Dr Mason provides independent expert reports for criminal and civil cases, both prosecution and defence.

Annex A – How prosecutors should use this toolkit

What is the purpose of this toolkit?

This toolkit has a number of specific objectives:

To assist prosecutors with their understanding of a range of pre-existing psychological conditions applicable to adults and highlight where expert comment may be required to facilitate a fair assessment of evidence;

To assist prosecutors with their understanding of a range of pre-existing psychological conditions applicable to children and adolescents and highlight where expert comment may be required to facilitate a fair assessment of evidence;

To assist prosecutors with their understanding of post-traumatic stress disorder and to highlight where there may be opportunities to adduce expert evidence in accordance with R v Adam Eden R ;

To assist prosecutors with understanding the support that an individual suffering from a particular condition is likely to require during their journey through the criminal justice process from ABE to giving evidence at trial;

To assist prosecutors with understanding how the approach taken to the treatment of a pre-existing condition can impact upon the reliability of memory and the potential for the creation of ‘false memories’;

To assist prosecutors with understanding the psychological effects of rape and sexual assault in order to increase understanding of the typical behaviour patterns of traumatised complainants thus protecting against the undue influence of myths and stereotypes in decision-making;

The importance of Code-compliant decision making

The toolkit is not intended to provide a means by which prosecutors can justify proceeding with cases that do not meet the Full Code Test.

All prosecutions must comply with the Full Code Test and it is hoped that this toolkit will support prosecutors in reaching properly reasoned and lawful decisions when applying the Code.

https://www.cps.gov.uk/publications/code_for_crown_prosecutors/

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Psychological Evidence Toolkit - A guide for Crown Prosecutors | The Crown Prosecution Service

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When a complaint is made, the understanding of pre-existing mental ill health, and potential psychological reactions to sexual assault and its aftermath, are vital considerations for a number of reasons. When a victim seeks help and discloses what has happened, the individual’s (and society’s) respo…

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Trauma Resilience in the UK Policing Project

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Trauma Resilience in the UK Policing Project

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The Trauma Resilience in UK Policing project explored how to better support the brain's ability to process trauma exposure and maintain resilience in contemporary operational policing. The project was sponsored by Police Care UK and works in collaboration with the Department of Sociology. Together, we provided practical techniques, training material and evidence-based insight to bring real effective change to trauma management for police officers, staff and their families- material and training that is still available today.

The project was reported on by BBC News, BBC Inside out, Channel 4 Dispatches and The One Show as well as having featured in the national press, including newspapers, digital coverage and radio throughout 2019. The study was also selected for the Cambridge Research Evaluation Framework (REF) 2021 and nominated for the Vice Chancellor's Research Impact and Engagement Awards 2019. Here is a testimonial to the work from AC Neil Basu QPM National Lead for Counter Terrorism Policing
"Counter Terrorism Policing is full of officers and staff who do not need to be motivated to stop terrorists. They get up every day to put themselves psychologically and physically in harm's way on behalf of the public they are sworn to protect. But, behind the badge they are human beings who experience the most terrible things and it has a profound impact that needs training care and support - precisely the kind of training, care and support you provide. I am more grateful for your help than I can possibly express in this short statement but simply I say - thank you."
What did we get up to?...

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The Trauma Resilience in UK Policing project explored how to better support the brain's ability to process trauma exposure and maintain resilience in contemporary operational policing. The project was sponsored by Police Care UK and works in collaboration with the Department of Sociology.

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A study of trauma management and well-being

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'pandemic policing':Highlighting the need for trauma-informed services during and beyond the COVID-19 crisis

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'pandemic policing':Highlighting the need for trauma-informed services during and beyond the COVID-19 crisis

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Return to Article Details Pandemic policing: Highlighting the need for trauma-informed services during and beyond the COVID-19 crisis Download Download PDF

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Return to Article Details Pandemic policing: Highlighting the need for trauma-informed services during and beyond the COVID-19 crisis

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Book: In the Realm of Hungry Ghosts by Gabor Mate 

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Book: In the Realm of Hungry Ghosts by Gabor Mate 

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I'm not much of a fangirl until it comes to doctors or scientists that step out of the box of the limited view of their academic training and start learning and teaching from their experiences.

Open-mindedness is S-E-X-Y.

So I fangirl all over the place when it comes to Gabor Maté. Not only is he from my home country (Canada), he has spoken on trauma as being at the root of addiction, mental illness and a number of other behavioural "disorders"--trauma as defined as a disconnection from oneself--...more

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I'm not much of a fangirl until it comes to doctors or scientists that step out of the box of the limited view of their academic training and start learning and teaching from their experiences. Open-mindedness is S-E-X-Y. So I fangirl all over the place when it comes to Gabor Maté.

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Book: Trauma and Recovery by Judith Herman 

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Book: Trauma and Recovery by Judith Herman 

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I'd be curious to hear what you read that seemed victim blaming. I didn't read anything near victim blaming. In fact Herman almost errs on the other sI'd be curious to hear what you read that seemed victim blaming. I didn't read anything near victim blaming. In fact Herman almost errs on the other side if anything. She goes to great lengths to say that people cannot remain morally neutral and must take sides and place the blame on the perpetrator. My few criticisms of Herman would be that she does label post traumatic stress a disorder (which seems slightly shaming) and she does not go far enough telling victims to take pride in their battle scars for having survived awful things. She could also go a bit farther as some authors have done and say that, "It's not genetic." I think the entire spirit of the book is non victim blaming though. Shawna Mathew...more (less)

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I'd be curious to hear what you read that seemed victim blaming. I didn't read anything near victim blaming. In fact Herman almost errs on the other sI'd be curious to hear what you read that seemed victim blaming. I didn't read anything near victim blaming.

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Book: The Body Keeps the Score by Bessel van der Kolk 

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Book: The Body Keeps the Score by Bessel van der Kolk 

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Hello, you are using an old browser that's unsafe and no longer supported. Please consider updating your browser to a newer version, or downloading a modern browser. Skip to Main Content Clients who are exhibiting behaviors are often labeled or diagnosed without an understanding that many social disorders are a result of adversity and past traumatic events.

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Nearly 35 million U.S. children have experienced one or more types of childhood trauma, reports National Survey of Children's Health (NHCS).

Studies show trauma is toxic to children's developing brains and inhibits their ability to learn in the classroom. However, studies also indicate that just one healthy relationship with an adult can help enable a child's brain to heal.

This is where the trauma-informed approach comes in. This approach looks at how the children's behavior, brain functioning and traumatic experiences are connected. The science behind the approach is based on Neurosequential Model of Therapeutics (NMT) and Neurosequential Model in Education (NME) developed by world-renown child psychiatrist, Dr. Bruce Perry, M.D., Ph.D., founder and senior fellow of the ChildTrauma Academy. Dr. Perry worked in collaboration with Steve Graner, M.S., NME project director, to develop NME.

At the beginning of the school year, we implemented a trauma-informed program based on NMT and NME at a high school in Long Beach. In just a few short months, we're already seeing a difference.

So how does this approach look practically?

While certified training in NMT and NME is crucial to successfully implementing the trauma-informed approach, there are a few ways that you can start incorporating this healing approach in your classroom now.

1. The foundation of being trauma informed is understanding.
Applying the trauma-informed approach means seeing the children through the trauma-informed lens. Changing your perception starts with understanding what trauma is; what it does to the child's brain and nervous system; and how that physiology can result in the troubling behaviors we see in students like difficulty learning, easily distracted, low motivation, defiance, irritability, anger outbursts, substance abuse, etc. Understand that these behaviors are always attempts at soothing emotional distress (dysregulation). And, understand and truly believe that much of what these children do is out of their conscious control.

2. It's not necessarily what you do, but rather who you are to the child.
Memorize these words: "Relationships are the agents of change and the most powerful therapy is human love." - Dr. Bruce Perry
It all starts with love, but what does that look like in action? You must be patient, kind, understanding, empathic, and nurturing... unconditionally. Healthy relationships start with a bond of trust, and trust can be established when children see that you will continue to love and accept them - even when they're at their worst.

Take time to truly understand them. They will test you to determine if you really are a safe adult. Be patient, and they will let you in at their own pace. Connect with them. Listen to what they are trying to tell you. They will try to share their pain, but often in a veiled manner. Just listen, reflect, and validate.

Picture this: A child comes to school in an angry mood because his father berated him about being lazy and stupid that morning. Instead of responding with "Well, I'm sure your dad loves you." Try "That hurt you so much to hear him say that to you." Don't try to minimize their feelings, or help them see things in another way in hopes they won't think things weren't or aren't really that bad. Most likely their life experiences are that bad.

Instead, give them hope of what good relationships can be like. What they can be, what a safe community can be. They likely have never known any different than what they've experienced and assume that's just how the world is. They have an inner child that is deeply wounded. Search for that inner child and connect with them there.

Stay tuned for part two where Nathan provides more tips on creating a trauma-informed classroom!
Nathan Swaringen, LCSW, is a School Based Clinical Therapist at The Guidance Center. In this role, Swaringen helps guide children and families toward positive and productive futures through mental health treatment. Swaringen is also leading a trauma-informed pilot program based on ChildTrauma Academy's Neurosequential Model in Education at a high-risk Long Beach high school. He is passionate about working with school staff to create nurturing environments where all students can thrive. Swaringen earned a Master of Social Work from University of Southern California, and Bachelor of Arts in Psychology from California State University, Fullerton.

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Five Ways to Create a Trauma-Informed Classroom Pt. 1 | The Guidance Center

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Nearly 35 million U.S. children have experienced one or more types of childhood trauma, reports National Survey of Children's Health (NHCS). Studies show trauma is toxic to children's developing brains and inhibits their ability to learn in the classroom. However, studies also indicate that just one healthy relationship with an adult can help enable a child's brain to heal.

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Trauma is one of the leading threats to a human's physical and emotional health. While adults can be affected by traumatic life events after age 18, childhood ACEs (Adverse Childhood Experiences) can have the greatest effect on our lives. We've chosen seven podcast episodes that can help you better understand the deep-seated effects of ACEs and stay trauma-informed this year.
Please note: the following episodes may contain instances of abuse, trauma, or mature language. Listener discretion is advised.
How Childhood Trauma Affects Health Across A Lifetime by Nadine Burke Harris

Dr. Nadine Burke Harris is emphatic about protecting children's mental health, specifically in low-income areas of the United States. During her TedMed talk, Dr. Harris addresses the single largest public health threat we are facing today: childhood trauma.

The CDC found that childhood trauma dramatically increases the risk of death for adults - an almost 20-year difference in life expectancy. ACEs affect brain development, the immune system, hormones, and even the way our DNA is read. Studies also show that children living at or below the US poverty level are much more likely to experience ACEs from birth to age eighteen.

Listen to Dr. Harris' TedTalk about acknowledging, treating, and preventing childhood trauma in our nation.

iTunes | Spotify | YouTube

A Crash Course on Trauma-Informed Teaching by Truth for Teachers

How do you cultivate and maintain a trauma-sensitive classroom? Often times, we may mistake our students' negative actions as personal or intentional. In reality, they may be responding to their current or past trauma.

In this episode of Truth for Teachers Podcast, Angela Watson offers a simple guide to shaping a trauma-informed classroom. This includes simple preventative and interventive measures as well as the importance of setting boundaries.

iTunes | Spotify | Listen online

Traditional Parenting vs. Trauma-Informed Parenting by The Forgotten Podcast

Raising a child that's experienced traumatic life events may look a little different than traditional parenting. Perhaps your child has experienced extreme food insecurity, domestic abuse, a house fire, or the loss of a parent. Simple events like a family pillow fight or a book dropping to the ground may cause a child to react in flight (running away), fight (becoming hostile or worked up), or freezing (not speaking or isolating themselves).

Jami Kaeb and author/seasoned foster parent, Kristin Berry, provide practical insight for parents, foster parents, and guardians who are longing to connect with their children. Particularly those who have been traumatized by big life events.
Please note: This episode has religious undertones with a trauma-informed central message. ChildSavers is a non-religious, non-partisan organization with an appreciation for all people working to improve children's mental health and development.
iTunes | Spotify | Listen online

Bessel van der Kolk - How Trauma Lodges in the Body by On Being

You won't want to miss Peabody Award-winning broadcaster, Krista Tippett, as she interviews psychiatrist and Boston University professor, Bessel van der Kolk. During this hour-long conversation, you'll learn how some experiences imprint themselves in not just our mind, but our body as well.

iTunes | Spotify | Listen online

What Happened to You (Part 1, 2 and 3) by Terrible, Thanks For Asking

Terrible, Thanks for Asking (TTFA for short) is about as real as it gets. Throughout this three-part series*, Nora McInerny urges us to ask "what happened to you" instead of "what's wrong with you?" Listen to Brit's 3-part story of building resilience to her childhood trauma.
*Please note these episodes contain mature language and instances of verbal abuse.
Part I Episode 85: iTunes | Spotify | Listen online

Part 2 Episode 86: iTunes | Spotify | Listen online

Part 3 Episode 87: iTunes | Spotify | Listen online
ChildSavers In addition to services for children, families, and child care providers, we offer trauma training to help teachers, parents, schools, and community leaders stay trauma-sensitive. Learn more about our training opportunities or schedule a personalized training event in your area. ' mission is to guide our community's children through life's critical moments with trauma-informed mental health and development services. With nearly 100 years of service in Richmond, VA, our staff works relentlessly to ensure all children can be safe, happy, healthy, and ready to learn.

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7 Podcast Episodes to Help You Stay Trauma-Informed - ChildSavers

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Trauma is one of the leading threats to a human's physical and emotional health. While adults can be affected by traumatic life events after age 18, childhood ACEs (Adverse Childhood Experiences) can have the greatest effect on our lives. We've chosen seven podcast episodes that can help you better understand the deep-seated effects of ACEs and stay trauma-informed this year.

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Podcast: trauma, resilience, and healing with Bruce Perry

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Podcast: trauma, resilience, and healing with Bruce Perry

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This week I'm talking to Oprah Winfrey and Dr. Bruce Perry about their new book, What Happened to You? Conversations on Trauma, Resilience, and Healing. We define trauma and talk about why big and small traumas activate our stress response systems and create emotional, physical, and social consequences, and how we can find the path to healing.

Listen

For the latest from Unlocking Us

Guest Info

Oprah Winfrey

Bruce D. Perry, M.D., Ph.D.

Dr. Perry is the Principal of the Neurosequential Network, Senior Fellow of The Child Trauma Academy and a Professor (Adjunct) in the Departments of Psychiatry and Behavioral Sciences at the Feinberg School of Medicine at Northwestern University in Chicago and the School of Allied Health, College of Science, Health and Engineering, La Trobe University, Melbourne, Victoria Australia. Over the last thirty years, Dr. Perry has been an active teacher, clinician and researcher in children's mental health and the neurosciences holding a variety of academic positions. His work on the impact of abuse, neglect and trauma on the developing brain has impacted clinical practice, programs and policy across the world. Dr. Perry is the author, with Maia Szalavitz, of The Boy Who Was Raised As A Dog, a bestselling book based on his work with maltreated children and Born For Love: Why Empathy is Essential and Endangered.

Show Notes

What Happened to You? Conversations on Trauma, Resilience, and Healing by Bruce D. Perry, M.D., Ph.D. and Oprah Winfrey

Through deeply personal conversations, Oprah Winfrey and renowned brain and trauma expert Dr. Bruce Perry offer a groundbreaking and profound shift from asking "What's wrong with you?" to "What happened to you?" Here, Winfrey shares stories from her own past, understanding through experience the vulnerability that comes from facing trauma and adversity at a young age. In conversation throughout the book, she and Dr. Perry focus on understanding people, behavior, and ourselves. It's a subtle but profound shift in our approach to trauma, and it's one that allows us to understand our pasts in order to clear a path to our future―opening the door to resilience and healing in a proven, powerful way.

VIEW TRANSCRIPT

Podcasts
Brené Brown Education and Research Group, LLC, owns the copyright in and to all content in and transcripts of the Unlocking Us and Dare to Lead podcasts, with all rights reserved, including right of publicity. WHAT'S OK: You are welcome to share an excerpt from the episode transcript (up to 500 words but not more) in media articles (e.g., The New York Times, LA Times, The Guardian), in a non-commercial article or blog post (e.g., Medium), and/or on a personal social media account for non-commercial purposes, provided that you include proper attribution and link back to the podcast URL. For the sake of clarity, media outlets with advertising models are permitted to use excerpts from the transcript per the above. WHAT'S NOT OK: No one is authorized to copy any portion of the podcast content or use Brené Brown's name, image or likeness for any commercial purpose or use, including without limitation inclusion in any books, e-books, book summaries or synopses, or on a commercial website or social media site (e.g., Facebook, Twitter, Instagram, etc.) that offers or promotes your or another's products or services. For the sake of clarity, media outlets are permitted to use photos of Brené Brown from her Media Kit page or license photos from Getty Images, etc.
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Brené with Oprah Winfrey and Dr. Bruce D. Perry on Trauma, Resilience, and Healing | Brené Brown

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This week I'm talking to Oprah Winfrey and Dr. Bruce Perry about their new book, What Happened to You? Conversations on Trauma, Resilience, and Healing. We define trauma and talk about why big and small traumas activate our stress response systems and create emotional, physical, and social consequences, and how we can find the path to healing.

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Research in Practice blog: TI practice & relationships 

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Research in Practice blog: TI practice & relationships 

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I once worked with a young mum who had been referred to a mother and baby assessment unit. The unit was nicely decorated to make it family friendly and homely. As we sat together talking about her baby, I remembered that this mum had been in care.

I asked her what it was like to be back in the system, this time as a mother. She told me about how she had been sexually and physically abused by a member of care staff and that she had managed this by being a 'bad little girl' who was always naughty and loud. We talked about how clever a strategy this was to protect herself as a child, but how this way of managing might not serve her as well now.

After we had spoken I couldn't help noticing the things about the assessment unit that gave it away as not being a proper home. The fire extinguisher on the wall, the heavy doors, the staff office at the front of the building with a latch on the door. It occurred to me that this might have been very like the building that this mum had been housed in as a child. A place that looked like a home, but wasn't. I wondered if she might be subtly triggered by these physical reminders of her childhood abuse and if she was in a state of reliving her trauma while trying to look after her baby. Surrounded by people who seemed to mean well, but also reminded her of her abuser. Sadly, the assessment unit stay did not go well. However, I think that this mum and I were able to think together about the impact her traumatic past was having on her life now. Also how important it was to separate out the past from the present in order for her to have a different future with her baby.

This story can help us to be in touch with what it is like to live with trauma. Sensing that no matter where we turn, there are reminders all around us of terrible things that may have happened. That often the strongest reminders of trauma are not outside at all, but inside our minds and bodies, like unwanted guests who refuse to leave us in peace (Fraiberg et al, 1975). It speaks to the fact that for many traumatised young people, the behaviors they display, which we consider challenging, are actually ways they have learnt to try and protect themselves (Ford and Blaustein, 2013). This young mother's story also helps us to understand how difficult it is for survivors of trauma to trust that help offered by authority figures, such as professionals, is genuine and that the intimacy offered by a therapeutic relationship is different from the forced intimacy and abuse that characterise physically and sexually abusive relationships. It helps us remember the uncomfortable truth - that many of the young people in our social care, mental health and justice systems are victims of abuse and neglect (Young Minds, 2018) and that sometimes rather than helping them, service provision can inadvertently lead to retraumatisation (Ho et al, 2008).

Trauma-informed approaches

One way to work with traumatised young people is to build upon social work's commitment to relationship-based practice and develop services that adhere to the principles of trauma-informed approaches. The core components of this approach, and some suggestions for how they might be enacted by practitioners and then experienced by young people, are detailed below (Sweeney et al, 2016):

Conclusion

For professionals working in a trauma-informed way - listening to young people carefully, helping them recognise how past experiences influence their ways of relating to the world today and offering a trustworthy relationship where they can try to build a safer life for themselves - might be the most important service we can offer them (Knight, 2015). It is through this re-forging of social bonds and the development of different types of relationships that young people can learn to live with the legacy that trauma leaves and where the hope for a different type of life can be fostered.

Related resources

Resources relating to trauma research and trauma informed approaches

How trauma research is being used in the UK

A social work piece on re-traumatisation

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Trauma-informed responses in relationship-based practice | Research in Practice

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I asked her what it was like to be back in the system, this time as a mother. She told me about how she had been sexually and physically abused by a member of care staff and that she had managed this by being a 'bad little girl' who was always naughty and loud.

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Infographic: how the nervous system responds to trauma

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Infographic: how the nervous system responds to trauma

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Trauma informed care (with links to several podcasts) 

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Trauma informed care (with links to several podcasts) 

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Over the last 20 years, there has been increasing recognition of the role that psychological trauma plays in a wide range of health, mental health and social problems. When people think of trauma, they think about experiences like war and the diagnosis of post-traumatic stress disorder.

The reality is that trauma includes a wide range of situations where people are physically threatened, hurt or violated, or when they witness others in these situations. This includes such experiences as childhood physical and sexual abuse, domestic violence, witnessing domestic violence, serious accidents, natural disasters, physical torture, riots, shootings, knifings, being threatened with a weapon, combat, house fire, life-threatening illness, and death of someone close, especially sudden death.

Although, there have been no comprehensive studies of the prevalence of exposure to traumatic events, studies conducted in the United States such as Kessler's Posttraumatic stress disorder: The burden to the individual and to society suggest that exposure to traumatic events occurs in at least 50%-60% of the U.S. population, and rates in clinical settings run much higher. However, problems like child abuse and domestic violence are challenges faced by almost all the societies on our planet, and natural disasters certainly affect everyone, regardless of national origin.

The impact of living through traumatic events, especially multiple events over the course of a lifetime, can result in a range of behavioral health problems other than post-traumatic stress disorder, including substance abuse, depression, anxiety problems, childhood behavioral disorders, psychosis, and some personality disorder diagnoses.

Some psychiatrists have suggested that the entire medical model of mental illness needs to be reevaluated in light of the recognition of the role of trauma (e.g. see Canadian psychiatrist, Dr. Colin Ross's book The Trauma Model)- this is not to say that biology doesn't play a role in behavioral health problems, only that it doesn't, by itself, cause them in most circumstances.

The reality is that social workers have been working with trauma survivors from the first day our profession began. However, the growing knowledge base about how trauma affects people is now being used to inform changes in policy and practice to ensure that we support recovery and don't inadvertently hurt people. Simply stated, trauma-informed practice is policy and practice based on what we know from research about the prevalence of trauma and about how affects people. Within the U.S., trauma-informed practice is usually referred to as Trauma-Informed Care (TIC), a term that is used in national policy efforts initiated by the Substance Abuse and Mental Health Services Administration and the National Child Traumatic Stress Network.
What Does Trauma-Informed Practice Actually Look Like?
Trauma-informed practice incorporates assessment of trauma and trauma symptoms into all routine practice; it also ensures that clients have access to trauma-focused interventions, that is, interventions that treat the consequences of traumatic stress. A trauma-informed perspective asks clients not "What is wrong with you?" but instead, "What happened to you?"

However, trauma-informed practice also focuses our attention on the ways in which services are delivered and service systems are organized. Recognizing that traumatic events made people feel unsafe and powerless, trauma-informed practice seeks to create programs where clients and staff feel safe and empowered. Generally, trauma-informed practice is organized around the principles of safety/trustworthiness, choice/collaboration/empowerment, and a strengths-based approach.

Trauma-informed organizations ensure that every staff member, from the receptionist to the executive director, understands trauma and trauma reactions. Trauma-informed organizations routinely examine all policies, procedures and processes to ensure they are not likely to trigger trauma reactions or to be experienced as re-traumatizing, that is, putting a client through a process that shares characteristics of the traumas they have lived through. For example, within psychiatric hospitals restraints have long been used for patients who are out of control in some way. However, for a person who has lived through abuse, restraint may well have been associated with being hurt physically or with being sexually abused.

Restraints therefore have a high potential to actually re-traumatize a client and trigger more psychiatric symptoms. A trauma-informed perspective recognizes the damaging impact of restraints and focuses on incorporation of psychiatric advanced directives into mental health care. This is just one example of a practice within mental health that can be hurtful to trauma-survivors. For more examples of how our efforts to help can inadvertently hurt people, read the heart-wrenching case study, On Being Invisible in the Mental Health System, that describes the devastating impact of the mental health system on one young woman's life and provides a compelling example of how our systems can fail trauma survivors.
Why Should We Care?
Each of us chose social work because we want to make a positive difference in the world. Some of us can see clearly where our work has this contribution. Many of us struggle to "do good" within service systems that are broken-we know at a basic level that something is very wrong, even if we manage to bring about positive outcomes much of the time. The systems within which many social workers are employed are often based on principles that are not only not trauma-informed, but instead, reinforce damaging messages to both staff and clients, such as "your voice doesn't matter here."

Bloom and Farragher in their book Destroying Sanctuary, have written eloquently about the current crisis facing our human services delivery systems and how the impact of our systems often is the opposite of creating safe and growth-promoting environments, both for clients and staff. While it may not be the only lens that can be helpful in addressing this crisis, a trauma-informed perspective shines a clear light on what's broken, what needs to change, and what will work instead.

It focuses us not only on our direct practice, but on organizations, service systems, and ultimately our paradigms for understanding the work we are doing and the work we would like to do-in other words, it's a true social work perspective. The paradigm fits well with the values of our profession, it draws attention to all that we know about a systems perspective, and it incorporates a holistic, biopsychosocial perspective on human beings.

It's because of all of the above reasons that our faculty chose to incorporate a trauma-informed perspective (along with a human rights perspective) into all aspects of our masters in social work program. We feel that this perspective is a missing piece in social work education and that having it will make a difference in our graduates being able to practice effectively at all levels of social work practice, especially in their ability to bring about needed transformations in our service systems.

Beyond the growing body of research that I've mentioned, part of what brought our faculty to this understanding was the feedback we were receiving from clients and agencies within our own community, Western New York, about the power of this perspective after years of incorporating it into our School's continuing education programs. Agency directors were becoming increasingly interested in seeking out trauma trainings for everyone in their agencies because of the transformational impact they were seeing with clients and the workforce. One after another, social workers and other human services professionals were describing this as "the missing piece" in their knowledge base and that having this knowledge made a difference in their practice.

Many social workers feel disempowered within the systems in which they work: trauma-informed practice is a framework of system and practice transformation that can provide us with a blueprint for empowerment for ourselves as well as for our clients. I hope I've piqued your interest in this concept enough that you'll consider learning more about it.
Where Can I Learn More About Trauma-Informed Practice?
Many of the resources cited in this post are good places to start to learn more about trauma-informed practice. In addition, try checking out the following:

Podcast interview (part 1) with Brian Farragher: The Sanctuary Model: Changing the Culture of Care - It Begins with Me (part 1 of 2) Episode #77 of the Living Proof Podcast Series

Podcast interview (part 2) with Brian Farragher: The Sanctuary Model: Changing the Culture of Care - Transforming Human Services (part 2 of 2) Episode #77 of the Living Proof Podcast Series

Podcast interview with Dr. Sandra Bloom: The Sanctuary Model: A Trauma-Informed Approach to Treatment and Services, Episode #10 of the Living Proof Podcast Series [note, I recommend listening to this after listening to the Farragher interviews]

Videos from a conference on trauma and trauma-informed care, including talks from two national presenters, Dr. Sandra Bloom (Sanctuary Model) and Dr. Robert Anda (ACE study)-videos included are Trauma 101, the ACE study, and an overview of the Sanctuary Model, one model of trauma-informed care.

Creating Cultures of Trauma-Informed Care (CCTIC): A Self-Assessment and Planning Protocol (pdf) by Roger D. Fallot and Maxine Harris, April 2009.

The book Trauma-informed practices with children and adolescents (2011) by William Steele and Cathy A. Malchiodi. London, Routledge.

Innovations in Implementation of Trauma-Informed Care Practices in Youth Residential Treatment: A Curriculum for Organizational Change (pdf) by Victoria Latham Hummer, Norín Dollard, John Robst, and Mary I. Armstrong. (article from Child Welfare)

Podcast I did for World Social Work Day: Trauma-Informed Social Work Practice: What Is It and Why Should We Care? (March 2012).

Online Trauma-Informed Clinical Foundation Certificate Program through our Continuing Education department (University at Buffalo School of Social Work)

A list of all the inSocialWork podcasts on trauma.

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Trauma Informed Care: What Is It and Why Should We Care?

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Over the last 20 years, there has been increasing recognition of the role that psychological trauma plays in a wide range of health, mental health and social problems. When people think of trauma, they think about experiences like war and the diagnosis of...

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Trauma and the Nervous System: A Polyvagal Perspective

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Podcast: Bruce Perry on childhood trauma and resilience 

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Podcast: Bruce Perry on childhood trauma and resilience 

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Childhood Trauma with Dr. Bruce Perry

Episode Summary

Dr. Bruce Perry joins Dr. Hanson and Forrest to discuss how we can understand, and hopefully recover from, traumatic experiences in childhood.

Episode Notes

Dr. Bruce Perry joins Dr. Hanson and Forrest to discuss the incredible impact of childhood experiences, the fuzzy distinction between trauma and stress, and what we can do to heal from those experiences.

As with all of our episodes dealing with trauma and traumatic experiences, please approach this material with care for yourself in mind. There are specific descriptions during the episode of neglect and abuse, including that perpetrated upon children.

Sponsor Message: We're now on Patreon, and we've made this week's expanded show notes available for free!
About Our Guest:
Dr. Perry is one of the world's leading experts on childhood trauma, and his clinical research and practice focuses on examining the long-term effects of trauma in children, adolescents, and adults.

He is the Senior Fellow of The ChildTrauma Academy, and a Professor at the Feinberg School of Medicine at Northwestern University in Chicago and the School of Allied Health at La Trobe University in Melbourne, Australia. Dr. Perry is also the author, with Maia Szalavitz, of The Boy Who Was Raised As A Dog, a bestselling book based on his work with maltreated children, and Born For Love: Why Empathy is Essential and Endangered.

Connect with the show:
Timestamps:
02:20: Why do early experiences have such a long-term impact?

06:10: What makes something traumatic rather than being merely stressful?

11:00: Summary of the material so far.

15:50: The Neurosequential Model of Therapeutics.

24:50: Respecting someone's developmental phase.

29:00: Practical examples of treatment for childhood traumas.

36:50: Self-help approaches to healing old trauma.

42:00: A message to your younger self.

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Dr. Bruce Perry joins Dr. Hanson and Forrest to discuss how we can understand, and hopefully recover from, traumatic experiences in childhood.

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Evaluation of trauma-informed practice at the YMCA

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Evaluation of trauma-informed practice at the YMCA

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Hickle, Kristine (2017) Trauma informed evaluation report. Project Report. YMCA Downslink Group & University of Sussex, Brighton.

Item Type: | Reports and working papers (Project Report)
Schools and Departments: | School of Education and Social Work > Social Work and Social Care
Subjects: | L Education
Depositing User: | Deeptima Massey
Date Deposited: | 24 Apr 2018 14:03
Last Modified: | 26 Apr 2018 08:39
URI: | http://sro.sussex.ac.uk/id/eprint/75374

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Hickle, Kristine (2017) Trauma informed evaluation report. Project Report. YMCA Downslink Group & University of Sussex, Brighton.

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promoting culturally competent trauma-informed practices 

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promoting culturally competent trauma-informed practices 

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Making the Business Case for a Vicarious Trauma-informed organisation 

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Making the Business Case for a Vicarious Trauma-informed organisation 

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Our vision is to provide appropriate training for schools,communities and organisations so that they become trauma informed and mentally healthy places for all.

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Center for Adolescent Studies | Competent Training for Professionals working with Adolescents

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If you work with youth there's a good chance you work with trauma. Trauma symptoms or adaptations as I like to call them (i.e., your mind/psyche finds ways to adapt to the difficult/dangerous experience for survival) manifest in many ways, from hyper-vigilance to flashbacks, from trust issues to dissociation, from altered world-views to avoiding specific people, places, or even thoughts of course this is not an exhaustive list). Youth from all walks of life can experience trauma. I've worked with marginalized youth of color from extremely poor neighborhoods and wealthy white youth with every privilege accessible, and have witnessed trauma manifest in many ways for the above and every population in between. Trauma will arises in your professional role (whether you're a therapist, educator, counselor, or other youth worker) and it only does disservice to the youth you work with if you're not aware of, and view youth behavior, through a trauma-informed lens.

It goes without saying that this brief article is simply an introduction, and that those who are truly trauma-informed have skill sets and practice qualities in their professional roles that far outnumber these four essential skill sets.
1) What is trauma and how is it caused?
The first essential in being a trauma-informed youth professional is to understand what trauma is and how it's caused. The Diagnostic and Statistical Manual of Mental Disorders (currently in its 5 th edition), which is the go-to text for mental health professionals, defines trauma as:

Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways: 1. Directly experiencing the traumatic event(s). 2. Witnessing, in person, the event(s) as it occurred to others. 3. Learning that the traumatic events(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental. 4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains, police officers repeatedly exposed to the details of child abuse). Note: Criterion A4 (the last one) does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related. (DSM 5, p. 271)

While this is a widely used definition of trauma, it's not without critique. It's first important to consider that trauma itself isn't the threatening or dangerous experience. What makes a horrible experience traumatic is how an individual, family, or community responds to it (e.g., that's why I like the term "adaptation" over symptoms. It speaks to the fact that people respond to trauma and attempt, unconsciously, to adapt and deal with it). The above definition captures a lot of experiences that cause trauma, however falls short in fully encapsulating the complexities of experience outside of single events. For example, it would be a stretch to fit the experience of racism into the above definition, yet there is extensive research supporting the notion that those who have been victims of racist events, ideologies, and institutional regimes can develop symptoms of trauma.

One of the most important studies regarding trauma, especially in youth, is the Adverse Childhood Experiences (ACEs) Study conducted by Dr. Vincent Felitti from Kaiser in collaboration with the Center for Disease Control. Briefly, this study investigated the childhood experiences of approximately 17,000 insured middle and older aged adults and found that folks who had at least 4 ACEs (from a survey asking about 10 ACEs) were much more likely to have a slew of psychological and medical problems that could result in early death. The 10 ACEs surveyed in the original study were:

Verbal Abuse

Physical Abuse

Sexual Abuse

Emotional Neglect

Physical Neglect

Divorce/Parent Separation

Domestic Violence

Alcohol/Drug Exposure

Exposure to Mental Illness and Suicide

Having A Household Member in Prison

Consider briefly the ACEs of emotional and physical neglect. It would be difficult to position these experiences within the DSM's definition and yet this is the most common form of abuse reported on youth in the United States and can lead to devastating consequences, one of which is trauma. The ACEs study was foundational in expanding the mental health field's view of what trauma is and how it's caused. It did not, however, include an exhaustive list of experiences with the potential to lead to trauma. Other experiences that lead to trauma included (but isn't limited to):

War, Terrorism, Mass Shootings

Refugee Encampment

Deportation of a family member

Life Threatening Illness

Natural and Unnatural Disasters

Motor Vehicle Accidents

Community Violence

Repeated Exposure to Trauma Details

Relational and Attachment-based trauma and,

Systemic oppression (racism, classism, sexism, etc.)

An evolving definition that I continue to edit for trauma is (using the DSM's above definition as a starting point as I am a psychologist by trade):

A response to actual, perceived, or threatened death, physical violence, sexual violence, neglect, serious injury, catastrophic natural disasters, unhealthy early child relational attachments, racism and/or oppression in one or more of the following ways: 1) Direct experiencing, 2) Witnessing the event(s) happen to someone else, 3) Learning the event(s) happened to a family member, close friend, or member of one's community, race, sexual orientation, etc., and 4) Repeated exposure to details of the event(s) via social media, images, intrusive thoughts and/or conversation.

I don't believe this is a perfect definition of trauma, but rather a starting point for dialogue about the different experiences that define what trauma is and how different populations experience it. As the field continuously evolves, it's my hope this definition will as well. For now, thinking about trauma from an expanded viewpoint like above will help you be a trauma-informed professional.
2) Understand how trauma affects the brain and learning
Another aspect of practicing trauma-informed care is having a basic understanding of how trauma affects the brain. Why? Because this will give you a much deeper insight into the next tip, how trauma affects youths' behaviors. I wrote about how trauma impacts the brain in another article that you can check out and will summarize here for brevity's sake.

Basically, the brain can be simplistically categorized into three layers: 1) the hindbrain; evolutionarily the oldest part of our brain that comprises the brain stem and cerebellum, this part of the brain controls our essential functions that we don't have to think about like breathing, heart beating, etc. Next is the mid-brain, also sometimes known as the emotional brain or emotional center. This is the limbic system and is comprised of the amygdala (our fear center), the hippocampus (which has to do with memory), the thalamus (which absorbs sensory information), and the hypothalamus (the messenger between the midbrain and hindbrain. Finally, the most recent layer of the brain from an evolutionary perspective is the forebrain. We share this (and the midbrain) with other mammals, but our forebrain is comparatively bigger than other mammals. This is the part of the brain responsible for language, abstract though, perspective-taking, and executive function.

Essentially, the take home point for how trauma effects the brain is that the thalamus absorbs sensory information (let's say a person walking toward you with a knife), the amygdala (think of this as the alert system) interprets danger (DANGER, DANGER, DANGER sirens go off), the hypothalamus then connects directly with the autonomic nervous system via the hindbrain and triggers you into fight, flight, or freeze (we'll go into these in depth in another post) mode and essentially all communication to your forebrain (the thinking, deciding, logical brain) gets cut off. That's why when someone is experiencing danger, or triggered trauma, it's difficult to make decisions, concentrate, and conduct simple executive tasks. If communication to the executive function part of the brain is cut off, how do we think that'll impact learning and behavior with youth in our classrooms, therapy offices, etc.? Right, it can have a drastic impact and sometimes when a youth in your class is being "defiant" it isn't always because they just don't like you or want to disrespect you. It can be because their trauma has been triggered. This understanding is essential for trauma-informed youth professionals.
3) View difficult, disrespectful, and defiant behaviors via a trauma-informed lens
Multiple traumas or even a single traumatic event could contribute to a slew of behavioral traumatic adaptations-that is the behavioral manifestation that the person adopts as a protective mechanisms to cope psychologically with the trauma they've experienced. These can be aggressive behaviors like fighting, physical intimidation, or verbal assaults; dissociative behaviors like becoming detached, extremely bored, feeling like reality is a dream, or like one isn't in their own body; humorous defensive mechanisms, overly compliant behaviors, and much more. They key here is not to over interpret everyone's behavior as trauma, but rather to consider the possibility that out-of-the-ordinary behaviors stem from trauma (e.g., a youth gets disproportionately angry with you when you ask a simple request; a youth is too compliant or perfectionistic; a youth is very "dazed" and often seems dissociated from their bodies, the present moment, and un-grounded). The general idea is to: 1) leave room for the possibility that an extreme or out-of-the-ordinary behavior from a youth is the result of them protecting themselves psychologically from their trauma and 2) that because this is a form of self-protection, you don't have to take it personally. If you take defiant, negative, aggressive behaviors as less personal, you will not only do your job much more skillfully and have a better shot at engaging and helping the struggling youth, but also will burnout less and practice much better self-care.
4) Work on yourself and your relationship-building abilities.
Your ego will play a big role in how you respond to traumatic adaptions from youth. Remember, these adaptations can show up as resistance, defiance, and any other youth behavior that can make you extremely uncomfortable. How you respond is essential, and this takes practice. Practicing not taking things personally is an art and takes time. For the truly traumatized, the behavior they're displaying is not about you. You may have triggered it, but it's about what happened to them and the unfortunate conditioned feedback loop that plays out in their behaviors as a result of it. If you remember that they're simply trying to protect themselves, you will take it less personally. Let that reminder be your practice, your mantra.

The second piece of working on you is self-care. The above framework is in itself a self-care practice, because it has the potential to prevent a lot of hurt in your life, but other self-care practices include mindfulness, exercise, spending time with friends, reading, going to the movies, or whatever it is you need to do to practice self-care.

4b) Working on relationship building skills:

Alongside the above, what's most important in engaging traumatized youth is making them feel safe so that they can eventually trust you. How's that done? The first step is building an authentic relationship. In a past post I overviewed 6 steps to building authentic relationships with youth. Most important to working with traumatized youth is the ego awareness work of setting healthy boundaries and engaging resistance from a place of understanding. Deeply listening to youths' stories and being genuinely curious about their lives, practicing appropriate self-disclosure to make them feel connected, practicing attunement-i.e., becoming attuned to the physical, mental, and emotional states of being and meeting them there, and of course the simple but powerful intention of just wanting to build a relationship and everything that comprises it; kindness, humor, compassion, and love, also contribute to building authentic relationships.

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The four essentials in this brief article should be viewed as a starting point for practicing trauma-informed care-this is not an exhaustive list but rather what's essential for engaging youth from a trauma-informed perspective; whether you're a psychotherapist, teacher, coach, social worker, mentor, probation professional, or other youth worker.

Related Posts
Compassion Can Help You Work with Trauma-Impacted Youth A Critical Intervention for Working with Traumatized Youth 3 Ways Traumatic Events in the Lives of Teens Impact Substance Abuse 4 "Must Read" Books for Professionals Working with Traumatized Youth
Check out the Trauma-Informed Care for Professionals Working with Youth online course for further training.

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The 4 Essentials of Being a Trauma-Informed Youth Professional | Center for Adolescent Studies

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If you work with youth there's a good chance you work with trauma. Trauma symptoms or adaptations as I like to call them (i.e., your mind/psyche finds ways to adapt to the difficult/dangerous experience for survival) manifest in many ways, from hyper-vigilance to flashbacks, from trust issues to dissociation, from altered world-views to avoiding specific people, places, or even thoughts of course this is not an exhaustive list).

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Jo Sharpen is the Policy Manager at Against Violence and Abuse (AVA). In this blog she explains how the effects of trauma can manifest in young people affected by domestic abuse, and how practitioners and services can understand and prevent re-traumatisation of young people. For an audio version of this blog, visit our Soundcloud profile or scroll to the bottom of the page.
The term 'trauma-informed' is becoming increasingly popular, but how does trauma relate to domestic abuse and how can we provide trauma-informed care for young people?
'Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being'[1].
Domestic abuse certainly fits these criteria and can be exacerbated by the fact that the trauma is perpetrated by someone close to the victim and by the unpredictable nature of abuse. There are many common responses to trauma such as hyper-arousal, numbing, increased startle response, flashbacks, avoidance, sleep problems, anxiety, memory and attention problems, developmental delays and attachment issues to name a few. These are all normal responses to abnormal situations, but on the surface may manifest as behaviour that may seem irrational, illogical or even risky. A concern then is that such behaviours could potentially be misdiagnosed as a child being defiant, oppositional or as having ADHD.

Young people who have experienced abuse are making complex, daily decisions about risk and safety. Due to the trauma response, they may be living mainly in the 'survival' part of the brain, constantly hyper-vigilant and scanning for threats and danger. This may come at the expense of higher reasoning, problem solving and logical reasoning. Sometimes this alarm response can still happen, even when the person is in a safe place. The brain stores memories of trauma that may be triggered by sounds, smells etc. and can result in an automatic, unconscious response.

We need to understand these responses so we can better support young people. Services often prioritise one issue whereas young people need a trauma informed approach which understands they may be experiencing multiple disadvantages (see the previous blog from Dr Kat Ford on adverse childhood experiences). Young people also need to understand that their responses are normal, as it can be very frightening and confusing especially if they can't make the links between their behaviour and their experiences.

If we do not respond appropriately, we risk re-traumatising someone. For instance, excluding a teenage from school for 'misbehaving' can remind them of abuse or rejection. Similarly, closing a case when someone does not engage or show up to appointments does not allow for the fact that simply leaving the house can be difficult when experiencing abuse or recovering from trauma.

A trauma informed response focuses not on what is 'wrong' with someone, but rather what they have experienced.

For instance, instead of thinking a young person is disruptive or not engaging, we understand that they have been triggered; instead of thinking that a young person needs 'consequences' or anger management, we understand they need routine, support and self-worth.

SAMHSA's 'four R' model is a helpful reminder:

"A program, organisation, or system that is trauma-informed:

1. Realises the widespread impact of trauma and understands potential paths for recovery;

2. Recognises the signs and symptoms of trauma in clients, families, staff, and others involved with the system;

3. Responds by fully integrating knowledge about trauma into policies, procedures, and practices; and

4. Seeks to actively resist re-traumatisation."

What we must always remember is that the impacts of trauma are preventable and reversible. With understanding, training and support we can ensure we are providing a more appropriate and therapeutic response that will impact on the long term wellbeing of young people affected by domestic abuse.
For more information on how to create a trauma informed response for survivors of domestic abuse, please visit the Visit our Spotlight page for more resources, guidance and survivor stories to inform your work with young people. AVA website.

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A trauma informed response for working with young people affected by domestic abuse

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Jo Sharpen is the Policy Manager at Against Violence and Abuse (AVA). In this blog she explains how the effects of trauma can manifest in young people affected by domestic abuse, and how practitioners and services can understand and prevent re-traumatisation of young people.

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Young Minds Trauma and Adversity infographic

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Young Minds Trauma and Adversity infographic

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Rhythmic movement and butterfly hug explained 

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Rhythmic movement and butterfly hug explained 

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An intro into some rhythmic relaxation ideas including a butterfly hug by Dr Karen Treisman

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Environmental assessment for a trauma-informed space 

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Environmental assessment for a trauma-informed space 