CHILDHOOD TRAUMA

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CHILDHOOD TRAUMA PSYCHOSISPart one

• Peter Bullimore
• Hearing Voices Network UK
• Paul Hammersley
• Spectrum Centre
• Lancaster University UK

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Trauma

• DEFINITION
• An injury or wound violently produced
• OR
• An emotional experience or shock that has a
  lasting psychic effect (Websters New Twentieth
  Century Dictionary)

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Types of Trauma 1

• 1. Single blow trauma. Natural disasters,
  technological disasters, acts of terrorism,
  violent crime.
• 2. Repeated trauma. Combat trauma, political or
  other imprisonment, some forms of emotional,
  physical or sexual abuse

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Types of Trauma 2

• 1. Natural trauma. Unintentional injury,
  accident, act of god. Sometimes described as
  trauma of facility
• 2. Man made trauma. More likely to be prolonged
  and is harder to bear. Trauma dealt by a person.
  Sometimes described as trauma of agency.

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Types of Trauma 3

• If someone falls and breaks a leg, that is
  facility, if someone intentionally breaks another
  persons leg, that is agency (Gelinas 86)
• The most extreme trauma entails an attitude of
  malevolent intent on the part of the perpetrator.

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The Role of Trauma

• Trauma is related to early abuse and/or
  neglect, is in the histories of public mental
  health individuals who frequently are
  self-harming, high users of costly services and
  who carry multiple diagnosis- BPD, DID, or PTSD.

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General Population

• 10 of women and 5 of men are likely to suffer
  PTSD
• 33.3 will have symptoms lasting several months
• Those most vulnerable - inadequate social
  support, survivors of child hood sexual abuse

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Freud

• Emotional time bomb exploding after puberty
• Splitting, hysteria, suppression of memory,
  dreams and hallucinations
• Hysteria / post traumatic psychosis
• Healy, Masson Kingdon and Turkington

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Next fast forward 100 years

• Denial AMA 1975
• The influence of the Feminist movement (Armstrong
  1996)
• Minimisation
• Blame
• Acceptance but not psychosis

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Early research
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The Four big studies (2003 2006)

• Janssen et al
• Bebbington et al
• Spataro et al
• Whitefield et al

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Janssen et al 2004

• Data derived from a non-psychotic Dutch
  population (n4065), High proportion in high risk
  age group
• Subjects re-interviewed three times over three
  years, analysis of those who made the transition
  into psychosis
• Highly significant association between childhood
  trauma and transition into psychosis. Severe CSA
  in men increased presence of psychosis 49X

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Bebbington et al 2005

• Large scale British survey (n 10,500)
• Assessment of psychotic symptoms and nine
  different and defined victimisation experiences
  
• VIs CSA, bullying, running away from home,
  time in care, time in a childhood institution,
  expulsion from school, homelessness, violence at
  work, serious injury or assault

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Bebbington - Results

• Significant associations between victimisation
  experiences and psychosis in 8 of the nine
  categories
• CSA the most robust predictor of psychosis even
  after controlling for depression
• Results are highly suggestive of a social
  contribution to the aetiology of psychosis

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Spataro 2006

• Study designed to establish absolute veracity of
  abuse reports (n 1618)
• Forensic police and court reports examined in
  Victoria Australia to establish definite abuse
  cases.
• Individuals then followed up as adults to
  establish psychotic/ neurotic symptom profile

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Spataro- Results

• Weak non-significant associations between abuse
  and psychosis
• Also no association between childhood abuse and
  subsequent adult substance misuse
• Why
• Age (Abridged Weinberg Method)
• Sample bias

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Whitefield et al 2005

• ACE (adverse childhood experiences) study Very
  similar to Bebbington
• Survey N 17,377 (San Diego)
• 8 ACEs Emotional abuse, physical abuse, sexual
  abuse, battered mother, household alcohol/ drug
  use, mental illness in household, parental
  separation/ divorce, Incarcerated household
  member
• Regression analysis

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Whitefield et al

• Regression analysis
• Dose effect (all Ace increase likelihood of
  hallucinations)
• 7 or more ACE five times more likely than 0 aces
  to experience hallucinations
• hallucinations may be a marker for prior
  childhood trauma that may also underlie numerous
  other common health problems

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Summary
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Ucok et al 2007

• Trauma and pathology in first episode psychosis
  in Turkey
• Trauma histories in approx 33
• Trauma higher BPRS scores and suicide attempts
• Most significant relationship is between trauma
  and emotional abuse. As factor that has been
  repeated elsewhere

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Conclusions

• Causality Bebbington
• Marker Whitfield
• Strongest correlation in ALL studies CSA and
  hallucinations
• Clear dose effect
• Dissociation and PTSD
• Strong evidence of worsening of illness profile
• Age of onset
• Suicide

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Summary

• Very strong cross-diagnostic relationship between
  severe CSA and auditory hallucinations
• Severity of Trauma a crucial factor
• Dissociation / PTSD crossover
• Identical relationship appears in the major mood
  disorders

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Bipolar Disorder
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Unipolar Psychotic Depression
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Question

• If we do not ask about trauma
• what is the average length of
• time for someone
• to disclose?

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Trauma

• 12 years

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Trauma

• Unfortunate but true

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Do we ask? (Warne and McAndrew 2005)

• Most staff do not discuss sexual matters
  including abuse with service users in the
  assessment process
• Most service users would prefer to talk to a
  nurse rather than a doctor about sexual matters
  (less intimidating), and want nurses to initiate
  the discussion

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Why not

• Medical model
• Client to disturbed (avoidance)
• Creation of too much distress (Can of worms)
• Clients dont want to talk about it
  (rationalisation)
• False memory syndrome
• Carer Paradox

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Sexual Abuse invisibleWhy is there so little
treatment?

• Professionals do not recognize the abuse
• Symptoms vary greatly
• Symptoms surface years after abuse
• Abuse is rarely volunteered
• Avoidance and denial
• Misdiagnose
• Mid 70s not seen as a problem

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Substance Abuse and Trauma

• PTSD 5 times likelihood of alcohol abuse
  dependence
• PTSD and war veterans - 75 met criteria for
  alcohol abuse
• 60 women 20 men in alcohol recovery programs
  sexual abuse as child
• 80 reporting physical abuse as children - in
  recovery programs

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Core Beliefs

• The shame and despair that come from the
• powerlessness and unmanageability help
  crystallize the
• core beliefs about personal unworthiness that
  were part
• of the persons initial addictive system
• I am basically a bad, unworthy person
• No none would love me as I am
• My needs are never going to be met if I have to
  depend on others
• Sex is my most important need
• (Adapted from Carnes, 1989)

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The Addictive Cycle

• Preoccupation
• Ritualization
• Acting out
• Despair
• Shame blame cycle
• Unmanageability

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FOCUS ON TREATMENT AND ASSESSMENT Part Two
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Assessment and treatment

• Personal experience
• Peters story

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Assessment

• What is the first question I should have been
  asked on my very first admission to hospital?

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Assessing Psychological Resilience

• Insight into oneself and others
• Supple sense of self-esteem
• Ability to learn from experience
• High tolerance for distress
• Low tolerance for outrageous behavior
• Open-mindedness

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Assessing Psychological Resilience (Cont.)

• Courage
• Personal discipline
• Creativity
• Integrity
• Keen sense of humor, constructive philosophy of
  life that gives life meaning
• Willingness to dream dreams that inspire and give
  hope
• (Adapted from Wolf Mosnaim, 1990)

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Assessment Process

• You will have to ask questions to assess
• If symptoms are resulting from abuse.
• This should Based on the assessment of fully
  recalled memories.

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Assessment Questions

• In the course of the day/night, do you hear
  voices in or outside your head? What are they
  saying? What may cause you to hear these voices?
• Do you ever try not to feel your feelings or
  thoughts? Do you usually feel numb?
• (Graves)

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Assessment Questions (Cont.)

• Have you ever been a victim of sexual abuse?
• Have you ever observed sexual abuse?
• Have you ever been the victim of physical abuse?
• Have you ever observed physical abuse?
• (van der Kolk)

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Continue if Yes to Any of the Previous Questions

• Do you ever have day dreams or think about the
  sexual or physical abuse?
• Night terrors Do you have them? Are they
  nightmares?
• Do you think about the above abuse during the
  course of a day?
• If yes, how and when does it come about?
• (Graves)

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Voice profiling

• Voice profiling looks at who the voices are and
  how they influence you.
• The purpose of profiling is to make it clearer to
  yourself and others what exactly are the natures
  of your experiences and how they influence your
  life.

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• You need to try and identify who the voices are
  and how they affect you.
•  
• If you do not know who the voice/s are give it a
  name maybe one that sums it up.
•  
• A voice profile is a representation of who your
  significant voices are and how they affect you.
•  

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• This helps in two ways. Firstly, when you can be
  clear about the identity of the voice/s you tend
  to feel more in control.
•  Secondly, if people want to help you they can
  see from profiles what the real problems are and
  when you need them most.
• Remember profiles can change over time, for many
  people there are many voices, only one or two of
  them are usually problems, sometimes the other
  voices can be helpful.
• To start voice profiling use a I have just heard
  a voice check list.

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Facilitating Disclosure

• On your own think of a piece of information about
  yourself which you do not share with anyone else.
  It may be something that your family knows but
  your friends and colleges do not. It may be
  something no one else knows.
• Consider why you do not share this information
  with others, is it that you are afraid that you
  will be judged or misunderstood. Do you worry
  that you will be perceived as less professionally
  competent or less trustworthy personally?
• In pairs share your understanding of what
  prevents you from disclosing information. You do
  not need to disclose the information itself in
  order to do this.
• On this basis of your own experience explore what
  would help you to feel able to disclose this
  information you keep hidden. Perhaps you need
  certain assurances or the security of particular
  attitudes or beliefs on the part of others before
  you would reveal this information.
• Use this information to draw up good practice
  guidelines for staff for creating an environment
  which would facilitate the disclosure of intimate
  of difficult information.

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The Impact of Disclosure
CLIENTS FEELINGS

• Before disclosure fear of
• Disbelief or rejection. The client may have had a
  previous negative experience of disclosure.
• Shocking the helper. The client may feel that
  their experiences are too disgusting or revolting
  to be told.
• Cracking up. Afraid that they are going mad and
  that disclosure will confirm this.
• Overwhelming the helper of being overwhelmed by
  the powerful feelings associated with the abuse.
• Threats from the abuser being carried out if the
  secret is broken.
• Wasting the helpers time. Feeling that the abuse
  was not serious enough/ to long ago for help to
  be needed.
• Not being able to remember details of the abuse
  on conversely dragging up previously repressed
  memories.

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After disclosure

• Relived that the first step towards help has been
  taken.
• Feeling shocked leading to numbness and distress.
  
• Frightened of the consequences now the secret has
  been broken.
• Feeling bewildered, confused, some mixed feelings
  and that they are going mad.
• Concerned about the helpers reaction and needs
  reassurance.
• Angry and resentful towards the helper for
  encouraging them to remember.
• Completely calm, misleading the helper into
  thinking that the abuse holds no negative
  feelings.
• The client may revert back to previous coping
  strategies e.g. Alcohol, drugs, self harm.
• May become depressed, even suicidal.

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Examples of Non-Helpful Responses

• Oh my God. I cant believe anyone could actually
  do anything that horrible to a child. What your
  father did was disgusting. ( Shocked response)
• It sounds like you believe your father/ mother
  did these things to you. You were so young its
  hard to know what really happened. ( Disbelief)
• Why did you agree to have sex with him? Why did
  you not tell your mother? Why did it go on so
  long? ( Blaming)
• You say this experience is in the past and that
  youve coped with it. Why dont you move on then
  to the concerns you have today? ( Minimization)
• Tell me exactly what was done to you sexually. (
  Voyeuristic response)

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Part Three

• Recovery

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The recovery movement

• 1970s USA / Scandinavia
• Civil rights and womens movements
• The rights of the marginalized
• Anti discriminatory legislation
• Disability discrimination act UK
• Stigma held back this process extending to the
  mentally ill

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History

• 1980s
• Recovery books, articles, narratives conferences
• Research evidence - a consistent body of
  evidence showing significant improvement or
  recovery in half to two thirds of people even
  those with long standing illnesses

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William Anthony

• A person with mental illness can recover even
  though the illness is not cured, recovery is a
  way of living a satisfactory, hopeful and
  contributing life even with the limitations
  caused by illness.

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Recovery themes

• A great deal of research has been conducted
  asking what recovery means to individual service
  users
• The remarkable thing about this research is the
  consistency of the themes that emerge

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Hope

• Maintaining, regaining or reclaiming hope is
  consistently identified as crucial to the
  recovery process
• Moving away from despair or learned helplessness
• Hope is about the future a key aspect of Becks
  cognitive triad

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Acceptance

• Breaking through denial
• McGlashan 1975 - Integration and sealing over
  (sense of self)
• Birchwood 2003 - treatment non-compliance
• Hearing voices network

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Activity

• Active participation in life
• Active coping strategies
• Active illness management
• Work and recreational activity
• Active social and emotional life
• Sense of purpose

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Others

• Recovery not achieved alone
• Willingness to accept help when necessary
• Friends, family
• User groups
• Mental health services

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Turning points

• Almost always present in a recovery narrative
• Usually from a position of rock bottom
• Luck, generosity, input from significant other,
  medication change, therapy input, religion,
  reappraisal of self, acceptance, art or other
  creative activity, a pet a success experience

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Summary

• A philosophy and a process, not an intervention
• The suggestion that Recovery is an alternative to
  PSI / CBT is nonsensical the two complement each
  other
• What can we do to aid the process!

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Staff attitudes

• From Weaver (1998)
• Eleven key rules for mental health workers to
  apply to assist in the recovery process

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1. Autonomy

• I WILL STOP TRYING TO CONTROL THE SERVICE USERS
  LIFE

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2. Professionalism

• My professional success is based on the service
  users recovery progress

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3. Trust

• I will listen to, believe and value what the
  service user says

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4. Respect

• I will not treat a service user differently to
  anyone else

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5. Expertise

• I will have an in depth knowledge about and
  sympathy for the service users disability

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6. Autonomy

• I will not allow a service user to become overly
  dependent on me

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7. Hope

• I can give a service user hope or helplessness,
  it is my choice

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8. Potential

• I can always see potential in the service user

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9. Relationship

• I serve as a coach not as an authoritative mental
  health professional

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10. Attitude

• I will not become discouraged when a service user
  fails, or reject if he or she succeeds

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11. Self care

• I will take care of my whole being - Dealing
  truthfully and realistically with the spiritual,
  mental, emotional and physical aspects of my life

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Part Three

• How to ask about and respond to childhood trauma

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Asking The Question Course Workbook Childhood
Sexual Abuse and Trauma Enquiry and Response A
Workshop for Mental Health Care Workers
Acknowledgement This workbook is based on a
training manual developed by Auckland Rape Crisis
and The Department of Psychology at Auckland
University, New Zealand. Permission has been
granted to use this material from Dr John Read,
Professor of Psychology Mr Paul Hammersley Dr
Magdalen Fiddler and Peter Bullimore The
Spectrum Centre Institute for Health
Research University of Lancaster
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Ground Rules

• Personal well being
• Feel free to leave at any point
• Utilise staff support if necessary
• This is NOT the appropriate arena for personal
  disclosure
• Never use examples from your own life in the role
  plays
• Debriefing at the end of the day

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Method

• There will be five role plays, each related to a
  central feature of disclosure and response
• Work in teams of three (service user, staff
  member and observer)
• The scene for the role play will be set and
  played out by the facilitators. You will then be
  asked to role-play the scenarios
• Switch roles frequently

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The Five Role Plays

• 1. Setting the context
• 2. Direct questioning
• 3. Response to disclosure
• 4. Empowerment and support
• 5. Emotional response and follow up
  

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Background 1

• Enhanced care through
• 1. Dealing with real issues
• 2. Trauma based case formulation
• 3. Making sense of a psychosis
• 4. Not everyone wants to disclose
• 5. Not everyone wants therapy
• 6. Everyone does want to be listened to

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Background 2

• No need to ask if a trauma history has already
  been taken
• Always make it clear in your own notes if a
  trauma history has been taken
• Be clear if
• The issue has been dealt with
• The service user does not wish to discuss the
  trauma
• The service user reports no ill effects from
  the trauma

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Confidentiality

• Ensure confidentiality
• Be aware of your own Trusts local
  confidentiality policy
• Be explicit about what will happen to the
  information
• Be explicit with regard to your own legal
  responsibilities
  

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Role Play 1

• Setting the context

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Setting the context

• Not out of the blue
• Within the context of an established relationship
  where possible
• Ensure enough time
• Ensure immediate support if required
• Begin the assessment with funnelling questions
• 
  
  

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Funnelling

• From the general to the more specific
• 1. Can you tell me about your childhood, what
  were your parents like
• 2. What was the best thing about your childhood,
  what was the worst, was there anyone it was
  uncomfortable to be with
• 3. Can you tell me a little more, are you OK to
  continue?
• 4. Have you discussed this before with anyone?

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ROLE PLAY 2

• Direct Questions

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Direct Questions

• Remain calm at all times
• Show empathy but not shock
• Offer reassurance
• Enquire about physical, sexual emotional abuse
  and neglect
• The descriptor uncomfortable is advised for CSA
• Be prepared for a response of no.
• Be prepared for a reluctance to disclose
  

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Direct Questions

• Did a parent or other adult hit you hard enough
  to
• leave bruises or marks?
• Have you had any unwanted sexual experiences?
• Did anyone do anything with you sexually that
  you were uncomfortable with?
• Did you always have clean clothes and enough to
• eat?
• Did you ever feel that someone in your family
  hated
• you?

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Role Play 3

• Response to disclosure

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Response to disclosure

• Establish if this is first time disclosure
• Reaffirm the importance of the disclosure
• Stress belief
• Look out for unhelpful statements
• Do not promise to keep secrets
• Allow continuation at service users own pace
• Seek clarification if necessary
• Document using service users own words where
  possible

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Response to disclosure

• Acknowledge that disclosure is difficult
• Accentuate the positive potential
• Acknowledge the emotional reaction
• Be prepared for self-blame (very common)
• Be prepared for ambivalence

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Role Play 4

• Empowerment and support

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Empowerment and support

• If not first time disclosure ask about previous
  support
• If first time disclosure offer support
• Establish current safety of the service user
• Establish current safety of vulnerable others
• There is no mandatory need to report historical
  abuse if the service user is not now at risk, It
  is a personal decision
• You need to be aware of ALL support agencies in
  your locality

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Empowerment and support

• Have you had any previous help to deal with your
  feelings about what happened?
• There are people trained in counselling for
  these issues, would you like me to get you some
  support?
• Would you like further help from me to deal with
  these issues
• Are you safe now?
• As part of this I need to check that those
  around you are safe

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Role Play 5

• Emotional response and follow-up

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Emotional response and follow up

• Before ending the session it is essential to
  check how the service user is feeling
• Summarise the session to ensure youve understood
  
• Disclosure can lead to an outpouring of intense
  emotions from extreme relief and sense of
  achievement to numbness or even rarely,
  suicidality
• Look for immediate support from friends family of
  staff
• It is essential to formally arrange a follow up
  with yourself or another staff member

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Emotional response and follow up

• Telling someone what happened can sometimes
  bring up many feelings, how do you feel right
  now?
• Do you have someone who is a real support or
  help for you, that you could talk to or call If
  you needed to?
• Can we arrange a time for us to meet in the near
  future so that I can offer you support if you
  need it?

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Emotional response and follow up

• Telling someone what happened can sometimes
  bring up many feelings, how do you feel right
  now?
• Do you have someone who is a real support or
  help for you, that you could talk to or call If
  you needed to?
• Can we arrange a time for us to meet in the near
  future so that I can offer you support if you
  need it?

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Debriefing

• Thanks for your participation
• Take five minutes in your groups of three to talk
  about how you feel about todays session
• We will then take feedback
• The trainers will be available after the session
  for individual questions or concerns

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The Power of Communication No one had paid
George any attention for years. Now doctors,
attendants and nurses all talked to him and
watched eagerly to see what effect the drug would
have. His condition improved rapidly. After only
two weeks of the drug treatment he was moved to
a ward for less disturbed patients where he took
part in a number of activities. Soon he was
doing so well he was promoted again. By this time
he had lively relationships with other patients
and many members of staff. He began to spend
several hours a day with paints and clay, using
them to express the rich fantasy life that had
previously interested no one. His doctors
marveled. Attendants praised his skill. George
was released from hospital thirty-eight days
after his first dose of Thorazine. Whilst he was
signing out he remembered that he left something
behind, went back to his room returned with and
old sock. The puzzled attendant who asked to see
it found thirty-eight Thorazine pills carefully,
stashed inside the sock.
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Contacts

• peterbullimore_at_yahoo.co.uk
• P.hammersley_at_lancaster.ac.uk
• www.caslcampaign.org.uk