We are the Association for Child and Adolescent Mental Health, or ACAMH for short. And this is ACAMH Learn. Hi. I'm Dr. Ron Dodzro, a clinical psychologist and cofounder and director of PTSD, Psychologists The Streets Deserve. I have particular interest and passion within trauma and PTSD occurring from community violence, which is what we will be discussing today. We will be focusing on what we mean by community violence, its connection with trauma and PTSD, how it manifests, and how me and Dr. Amber attempt to provide healing and support for those affected. Take a look and please share widely with friends, colleagues, and those who experience or have experienced community violence. Hi. I'm Dr. Amber Qureshi. I'm a clinical psychologist, also a cofounder of PTSD, Psychologists The Streets Deserve. And I work for the NHS in the Youth Justice Service. When we talk about community violence, we're not just talking about one-off incidents or isolated cases. We're talking about the chronic, often normalised exposure to interpersonal violence in public spaces. It's violence that happens outside the home but inside the heart of the community. That could involve stabbings, shootings, assaults, or threats, often between people who know each other. Sometimes fueled by postcode tensions, gang dynamics, or cycles of revenge. It affects people directly and indirectly through witnessing or hearing about losing someone. Repeated exposure to community violence is a direct pathway to trauma. It disrupts your nervous system, makes you hyper alert, constantly scanning for threats. And when that sense of threat doesn't switch off, you start to see classic symptoms of post-traumatic stress disorder, which might include flashbacks, nightmares, emotional numbness, or a constant sense of being unsafe. But PTSD in this context doesn't always look like the textbook version. It might look like aggression, withdrawal, low trust in systems, or school disengagement. It's a trauma that's embedded in the environment, which is relational, systemic, and persistent. And because it often overlaps with poverty, racism, and a lack of safety nets, it's not just a mental health issue. It's a public health crisis. So when we talk about community violence and trauma, we're talking about the psychological cost of living in survival mode. So I'd say absolutely, definitely possible for someone to be traumatised without realising it, especially when violence is normalised in communities where violence is frequent, common, happens a lot, whether that's directly or indirectly. So vicariously people experiencing it. PTSD symptoms may often manifest differently than in clinical settings. So people may not recognise what they're experiencing or their distress as trauma per se. And instead, it might be seen as it is what it is or normal survival behaviour. And in this case, people may not label their experiences as trauma. So when I guess violence, threat, or even loss is a part of your everyday life, trauma stops feeling like an event or a traumatic event and becomes more like a baseline. And as a result, people may not always recognise their trauma. It's often masked by humour or even desensitisation because of violence, community violence in this context, is just so embedded in the environment. They may have not even been given a language for trauma or PTSD to be able to understand what's going on and/or to be able to discuss it. And also similarly, talking about feelings or vulnerability can feel quite dangerous or even exposing for people, whether that's talking to professionals about it, but also people in their network, friends, family, loved ones. I guess to the second part. So lots of less visible signs that can occur. Thinking about PTSD symptoms, we could consider that not talking about something. So for example, a loss in the community or not talking about emotions, instead saying it is what it is. That could arguably be seen as some avoidance framed within a PTSD context. Similarly, kind of hypervigilance, constantly looking over shoulders, avoiding certain routes to get somewhere, avoiding certain postcodes. All of this is also avoidance. This idea of survivor's guilt. So that could also contribute to a bit of a negative self-concept. So why am I alive why when others aren't. Things like that, I think, can also be a less visible sign of PTSD. Hyper-independence, feeling alone in the world. This feeling of maybe not being able to trust anyone. Difficulty sleeping. Constant tiredness that could result from rumination before wanting to go to sleep, or worrying when someone is alone and in their bed. Being labelled as badly behaved, unmotivated. Not being able to talk about emotions. Often sometimes I think there could be this label that's more behavioural as opposed to understanding psychologically what's going on. Trust isn't given. It's earned. And when someone's grown up in a world where authority means betrayal, judgement, or abandonment, they're not just cautious, they're protecting themselves. So me and Dr. Amber, we build trust through consistency. We just show up again and again in ways that say we see you, we hear you, and we're not going anywhere. So we approach it by, I guess, one, getting rid of this saviour complex. We understand that people have survived long without the need of our assistance and we respect that. We're not here to rescue people. We're here to witness, validate, and collaborate within their experiences. We name the elephants in the room. If there's distrust in the room, we don't dance around it. We say we know people in our position haven't always been safe or helpful. And that kind of honesty disarms defensiveness and can earn respect. We hold boundaries in humanity. We're clear, but not clinical. We're professional, but not robotic. I think we talked like human beings. Eye contact, humour, cultural fluency. All of that builds rapport. And we show up when it's inconvenient. Anyone can talk during sessions, but calling back when they've ghosted you, checking in when things go quiet, that's what builds credibility. We're slow to apologise, but we're quick to empathise. That rude or aggressive behaviour is often trauma in disguise. So we're curious and we use that curiosity over judgement. And that's one of our mottos. We also let people hold power. We ask them what they want. What works for them. Trust isn't built through control. It's built through shared decision making. So for us, the question isn't how do we get them to trust us. It's how do we become trustworthy in a world that hasn't been. Because that takes time, humility, and the willingness to walk beside it. I think honesty is also important within that too. I think we can't always know everything, or also have the same lived experience and just being curious about that, as Dr. Ron said. And being honest in naming that can be really helpful to build trust. And just being authentic, I think is also important. Being authentic I think is just extremely powerful. I think people can feel when you're being genuine or not. So I feel like that's also helpful. I think CBT, Cognitive Behavioural Therapy, can be helpful. I'm thinking of things such as using a hot cross bun or thought records just to break down what's going on. I think it can be quite useful to just use these tools as just understanding an experience of someone and piecing things together so their thoughts, their feelings, their behaviours, the physical bodily sensations. I think these tools are really helpful in just using that to understand what's going on. Similarly, CBT techniques such as behavioural activation I think can be quite useful, especially if someone is presenting with quite a lot of low mood and no motivation, for instance. Intrusive thoughts within an OCD context I think can be quite helpful. Some intrusive thoughts might be, for example, seeing someone and they're looking at me. Of course, I do want to validate that can be a very true experience for someone. And there may be a kind of threat there, of course. But I think holding in mind CBT tools that maybe less commonly used can be useful. Of course, thinking about PTSD and trauma-focused CBT can also be helpful. There's also lots out there about adapting CBT culturally, which I think can be useful. There's so many tools, so many papers that I tend to draw on for that. Narrative therapy is another model or type of therapy that I use. It's developed for people who have been exposed to repeated violence. And I quite like it because it separates the person from the problem and can help rewrite a story, which I think is extremely powerful. And often with the people we're working with, violence may become like a dominant narrative. So this idea of someone being bad or someone being trapped or someone being naughty, for example. So I think narrative therapy is really helpful in rewriting that or reshaping that and spotlighting some hidden strengths because oftentimes strengths can be missed. And I guess within the people that Dr. Ron and I have worked with, we do see loyalty, we see survival skills. And those are important to name as well as strengths. Similarly, NET, Narrative Exposure Therapy, something I use quite a lot. Again, it's designed in contexts where violence has been quite normalised. I quite like the lifeline exercise within that. So telling someone's story chronologically, focusing on sensory details of sounds, smells. Oftentimes we might think about the sound of the police sirens as something that can be really traumatic or triggering, thinking about emotions, body reactions. And I feel like within net, it's quite useful as a therapy because it can help to reduce shame and guilt. Social Graces by Burnham is a useful tool as well. I like to use this during assessments as a way to navigate conversations and particularly focusing on gender, race, age, socioeconomic status, education, and location. I think location is one that we don't always tend to use. At least I didn't when I used Social Graces. But I think within the context of the people that Dr. Ron and I work with, like location is really helpful to consider. We mentioned earlier about postcodes and the difficulty that can come with that kind of territory of living in a certain area. So I think location is really helpful to consider. And using the Social Graces as a tool can lighten that and help bring a bit of a framework in how we navigate that. Psychoeducation, in general, Dr. Ron and I love using music, TV, or cultural metaphors to explain different things. It might be trauma responses. It might be using a TV example. So for example, a UK show Top Boy, one of the main characters is actually experiencing panic attacks within that. So that could be quite a nice way to explain what a panic attack might look like, or what might be going on for that particular character. And it's helpful because it takes away from the person and using someone else as an example if it feels too difficult to talk about our own examples in that moment. We're quite creative. We like to use whiteboards. We have trauma card deck that we use as well. That can be helpful to just have something else there and there's usual visuals within that to talk about trauma. I completely agree with Dr. Amber. And one of the models that I hold dear, which she knows about is schema therapy, especially when I know that the young people we work with struggle with trust, as it was often broken quite early within their lives. So many of the young people that we work with operate with lots of what we call maladaptive schemas, like, I'm bad or people will leave me or the world is dangerous. And what schema therapy allows us to do is to turn those internalised beliefs into something that young people can understand and become more visible in regards to, but then also think about how they can adapt and change and reframe those narratives. I guess ultimately, what Amber has highlighted is that the work that we do very much takes an integrative, trauma-informed, and culturally-grounded approach, which for me honours the pain that people have gone through, but also their power, their strength, and resilience. Again, just I guess to add is not only do we work with individuals themselves, but we also work with professionals. So the network around someone working with the individuals, and we like to draw on mentalizing. So consider if we were in a meeting with the network right now, what would the young person be thinking? What would they say? How would they respond to what we're saying and how we're talking about them? And I think that's a really useful tool to hold in mind as well. You can't expect a young person to heal in isolation if the environment that hurt them stays the same. Something that Dr. Amber alluded to in a previous question is that we don't just work with individuals, we work around them. We work with families, carers, peer groups, the whole lot. We never assume the family can't engage or that they're part of the problem. We've both worked with parents who've lived through their own traumas, who've lost children to violence, or who are navigating systems that are constantly criminalising them rather than supporting them. And if you approach with judgement, then actually you're going to lose contacts. If you approach with curiosity, that's often where we see the breakthroughs in our work. We both lean on Bronfenbrenner's ecological systems theory. It reminds us that a young person isn't just shaped by their own experiences, but by everything around them, whether that's school, family, their neighbourhood, racism policies. So I guess what we do is that we invite the system into the room. We're kind of asking, who's in your corner? Who's got your back? Who do you go to when things get a bit crazy? Who needs to be part of this journey? And with that, I guess we run sessions where we're able to talk to parents and carers, not to tell them what's wrong with their child. But to actually help them understand about trauma responses. To understand the nervous system activation, how survival mode affects behaviour. So once they get that, their child isn't mad or the child isn't rude, but actually their child is hurting. Something shifts. Not everything that we do needs to be so clinical. And actually community healing can often look like prayer, music, shared food, and storytelling because these can be powerful tools for meaning making and connection. We're very much aware that not everyone's going to open up to a psychologist, but they might open up to a youth worker, that auntie at the community centre. So our role is then also about collaborating with and co-facilitating with those trusted messengers. And that's how we build a network of support. So for us, healing isn't just about what happens in the session. It's what happens after when the young person walks back into their home, their block, they're chilling with their friends. If those spaces don't feel safe, then, unfortunately, therapy just becomes a plus and a wound. So we bring the family and the community in not as an afterthought, but as the foundation of the work. I think one way to explore that as well is often using genograms and thinking about strengths of relationships within the family or close ones for individuals, but also mapping out just what the network looks like. And again, thinking about strengths. And that can also help us then do the work after all that Dr. Ron's named. So many of the people that we work with have survived and actually continue to survive unimaginable trauma. Things that occur often that they've just become their everyday life. The resilience, the humour, and insight of the people we work with is really, truly inspiring. And what gives me hope is when given the right support or given building rapport and trusting the process with someone, a lot of change can happen. And something to hold in mind is those small wins and they're important too. So having someone consistently turn up to an appointment despite them maybe not talking as much is a win. It's trust that's being built. And over time, as long as we remain consistent and show up for someone, hopefully there might be some more change in terms of how they interact with that appointment or how much they might open up. But turning up is still a small win. I find it hopeful when people are able to reframe what they're normalising or we're normalising and understand that, OK, maybe this isn't normal, or maybe I am struggling here. And then eventually go on to seek support. And I do want to name that as well because it's not always about getting the help straight away, but it might be helping someone understand how their experiences or past experiences have affected them and where to get support and what that support can look like. It's putting that nugget in, planting that seed, for example. Being able to navigate that conversation is a win itself and is really hopeful for change and healing. I'm inspired, actually, by the amount of people who do seek out support and want to create change in their lives, but it is their journey and they may not be ready in that specific moment of time, but just talking about something or helping them understand the experience or providing psycho ed is another way of feeling hopeful about something. Community sorority is also another thing. So people show up for each other, even when systems have failed them around them. And similarly, word of mouth. We have people coming in for support from us who have come based on something their friends said or based on something other professionals have told them. So I think that is also something that makes us feel hopeful that people do want to have these conversations, but it's maybe finding somewhere they feel safe enough to do so, or finding someone who they connect with or feel able to talk to about these things. I think also being able to use creativity is something that provides hope. I think the way that people we work with can turn maybe their experiences or pain even into music and art is something that's quite hopeful that these conversations can happen, but they're maybe not happening within a therapeutic space, for example. And how can we translate that in a way that feels comfortable to have these same conversations within those settings as well. Yeah. I would agree, Dr. Amber. To me, ultimately, it's the people. The people that have been written off, overlooked, overpoliced, but they still show up, they still survive, they still try. What gives me hope is watching a young person walk into a session after losing a friend and, say, I didn't want to come, but I'm here because it tells me that they haven't given up. It's seeing parents who've been through hell still fighting for their kids, even when they don't trust the system and often for good reason. It's communities that organise their own memorials, their own youth projects, their own informal therapy sessions in living rooms, barbershops, long before the professionals arrived. To me, it's just those micro moments, like the first time someone says, I never thought of it like that, or the first time someone stops blaming themselves for what they had to do to survive. Or the man who grew up in chaos but is now asking me, how do I break this cycle for my own son? So what gives me hope isn't the system. It's the spirit of people. The everyday refusal of people to be defined by what they've been through. Because we've both worked with individuals who've lost siblings, friends, their freedoms, and still they choose to feel, to trust, to build. And I guess for me, that's radical strength. Yeah, that's what gives me hope, the people. Because despite everything that they've been through, they're still here. Also, don't forget to follow us on social media. So for Instagram, that's @ptsdlondon. You'll catch us there posting on our stories of what we get up to, day in our life, that kind of thing. And also, we post on our feed of just work we've done. So if there's anything you would like to find out about what we do, that's the place to be. And also how you can get in contact with us. Instagram is a good shout too. And please also follow us on LinkedIn under Psychologist The Streets Deserve, where we share lots of our rationale and blogs about how we work and some of the tools that we use for advocacy to really support young people who are affected by community violence. You can also read about some of our critiques around traditional psychological models and ways of working. [MUSIC PLAYING]