We are the Association for Child and Adolescent Mental Health, or ACAMH for short. And this is ACAMH Learn. Welcome to Mind the Kids. I'm Dr. Jane Gilmour, honorary consultant, clinical psychologist, and child development programme director at UCL. And I'm Umar Toseeb, professor of psychology at the University of York, focusing on children and young people's mental health and special educational needs. In each episode, we select a topic from the research literature and, in conversation with invited authors, sift through the data, dilemmas, and debates to leave you with our takeaways for academics and practitioners. Today, we'll be discussing intervention following adverse childhood experiences. This episode is called Trauma Responsive Care-- It's All About Me. Right. So as with most of our episodes, I start from a position of knowing a bit about this, but not enough to do a full episode or a full conversation. So I'll start by just saying that I understand adverse childhood experiences, and I teach about adverse childhood experiences and their relationship to child and adolescent mental health. But I know very little about trauma-informed practise. So when I've heard the use of the word trauma, it's usually been when colleagues have been talking about research projects that they want to do and they want to take a trauma-informed approach. But I don't actually know what that means. But I do know a trauma-informed approach is very in vogue at the moment, and people are very interested in doing work on this. And this is something I'm going to be really interested to talk to Sarah about in more detail, because although I absolutely support the idea of trauma-informed care because there is an evidence that it has an impact on individuals who have had those experiences, I think by using the phrase as a bit of a personal frustration I have, because by using the phrase, it implies that there's an add on that, then you will offer trauma-informed care, where actually, there's lots of the principles in that package should be embedded anyway in good practise. So we're thinking about consistency. We're thinking about a low emotional tone in our interactions with young people. We're thinking about curiosity about what might have happened in the past. We're thinking about a sensitivity to why young person acts in a particular way. So although I think there is a-- and I like the way you've said invoke, because I think there is a danger that a phrase can be bandied around. And actually, what we need is practical strategies in routinized rather than additional ideas about trauma-focused care. But this is where I think Sarah will be able to help us explore that in a little bit more detail because there is actually a resource or Karen Treisman-- and Sarah may know of Karen as well-- has a book called A Treasure Box for Creating Trauma-Informed Organisations. And it's a wonderful resource. It's a really interesting book to look at. And it's got lots of practical strategies and it would bring to life some of the ideas. You're saying, I don't really know what it looks like. But it would really bring to life some of the ideas that I think we'll probably talk about in more detail today. Can I ask a clarification question, which is when we're talking about trauma-informed care, does that mean that when we provide care to children and young people, we should acknowledge that the children or young people have likely experienced trauma, or does it mean that the principles that we apply when we work with children and young people who have experienced trauma should be applied universally? Well, I think that's my question. I think, obviously, when we're dealing with a particular group of young people, there's a greater likelihood that they will have experience of trauma and be traumatised by it. And those are two separate things which Sarah will help us unpack in more detail in a moment. I guess my caution is that these principles should be embedded in practise anyway. And we would take extra care, I would say. This is how I would phrase it. But perhaps Sarah will correct me, that we would take extra care to think particularly about what might be triggering a young person, or why they might act in a particular way when they see a setting or a person or an accent or whatever that might be. But that curiosity about why young person would be acting in a very intense way is something that all clinicians must have in their toolkit. So I think it might depend somewhat on the population that we're dealing with. But one never knows what a young person brings into their therapeutic setting. And even if it's not a population that we would predict trauma might be around, we just don't know. And I think it does us all a good service to have that curiosity and sensitivity about wondering why a young person might be acting that way and considering trauma as a possible explanation. So I don't think I've answered that question, Umar. I'm going to probe more. So I see parallels here with the wider inclusivity movement. So when we were talking about neurodiversity previously or special educational needs, we think about how we can make educational practise more inclusive so that it accommodates for lots of different types of neurodiversity. Is it a similar principle here where we make therapeutic practise much more inclusive by taking this trauma-informed approach? Is that fair? Is it making it more inclusive? Is that what we're doing? I suppose, I mean, you could describe it as inclusive. I mean, I would suggest it's more sensitive, I guess, to be considering how the environment might impact on a young person and how, if we have a sensitivity to that, we will allow that young person to-- we're sort of situational shaping, if you like, setting up the environment so that they will be able to engage with the world, but also perhaps in this case in terms of therapeutic intervention because the environment is at its best for that young person. So I mean, there will be individual differences. And each individual person, particularly if they're very traumatised, will have a bespoke package if you like. But I also think there are general principles that we should all adhere to in terms of routinized and low emotionality in our care could be considered part of trauma-informed care. But I believe that that should be something that we should all consider or certainly have as a baseline. But I do think-- and there is evidence. And Sarah will describe this to us in more detail that, of course, the environmental shaping can have an impact, and a very positive impact if we can get that right. So to understanding that and understanding the nuance in that will be key to supporting young people who have experienced trauma and who are traumatised. As we said, two different things. I think now would be a good time to bring Sarah in. So let's do it. So today, we're joined by a consultant, clinical psychologist, Dr. Sarah Parry from the University of Manchester. Welcome, Sarah. Hello. Thanks for having me along. Thank you for agreeing to have this chat with us. Let's start with some very basic definitions. What is trauma? So in its simplest form, trauma is something that people might be exposed to. And each person will respond to traumas that they're exposed to in different ways depending on what has happened to them before that particular incident, and perhaps what personal resources that they have around them. What are some examples of childhood trauma? So I'm trying to think about adverse childhood experiences. So maybe we could start with a recap of that. But when does an adverse childhood experience become a traumatic childhood experience? And is there a clear distinction, is there a gradient, is it about severity, is it about frequency? So much of it depends on the context of the young person when something happens. And I should probably caveat to say my work is usually with children and young people. So I suppose I'm very much thinking about that particular sort of developmental period. But I think it can be quite unhelpful to think, well, what's more severe than something else because actually it totally depends on the person's life experiences and context before and around what happens. So in terms of what can be traumatic or retraumatizing to one person might be quite difficult for someone else. And I hear what you're saying, Sarah, about these individual differences, which are so important. So the impact will be different for individual people no matter what their developmental stage. But having said that, I'm interested in these developmentally sensitive periods. So if we say, all things being equal, a particular traumatic event may impact a child differently according to their developmental stage, is that something that is supported by data or is it entirely individually driven, if you like? Yeah, I'm not sure we've really got the answers to those sorts of questions, simply because there just simply has been a lot less research around the experiences and responses to trauma directly with children hearing about their unique context and settings. So without that youth led research, it's actually quite difficult to answer those broad questions because we just simply haven't heard from enough young people, from enough different situations, I suppose, to make those connections. But I think what we can think about is, well, what might be the particularly sensitive periods, what are some of the key transitions that children and young people go through, what are some of the unique first experiences that young people have, and how can that influence or shape-- you mentioned before kind of your environment-- in terms of those living environments the children are in every day, what can be contributing to shaping those and the experience of those environments and the people within them? And how can really pivotal moments during those kind of scene setting moments could influence how people make sense of those experiences? So I think we can certainly think about sensitive periods and critical event I think when we think about trauma. And I think particularly around how we conceptualise adverse childhood experiences as well. I think there's been lots of discussion over recent years as to how reflective of everyone's life might the list of ACEs be, and what might be some of the risks of tossing up an ACEs score rather than more developing a more individualised sense of how a young person's experiencing challenges in their life. So I think that's perhaps where the conversations are moving towards. And that's really helpful. And I like the way your highlighting that somewhat perfunctory idea. If we add up the score, there's an implication that there's a greater impact. Although I know that was the early literature was sort of sitting around that because one of the things I'm particularly interested in is about the teenage brain. And I'm thinking about that porous quality of the teenage brain. The brain absorbs the environmental experiences in order to learn so that they're ready for independence. And that it's a very time that they're going out into the world and proportionately exploring the world in different way and taking more risks. So the chances of having a traumatic event are increased. And potentially-- I'm hypothesising here again, understanding those individual differences-- that the experience will be deeper because of that environmental sponge that is the teenage brain. But that's really interesting. And I respect your caution about it's not a toss up and making these broad brush assumptions is less helpful for young people. Yeah. But equally, I think it can be quite helpful to think quite broadly as well. I think you mentioned about how it can be helpful just to look at how to make things more inclusive because more often than not, that then makes things more inclusive for everybody rather than one particular person or one particular group. And as you were saying before, Jane, there are key principles around trauma-informed care. And we can talk maybe a little bit more about that terminology as well that are good practise to be thinking about how to make spaces feel safe, to be thinking about how relationships can be mutually respectful and trustworthy, to be thinking about how to bring in consistency and predictability and all the things that we know from other areas of the literature are often key priorities across care settings. I suppose it's thinking about, well, how can we really amplify the responsiveness of those systems, relationships, approaches to care, to respond to the individual needs of a for person perhaps if there has been trauma in their history. Just picking up on that point on individual differences, I want to introduce the concept of coping here, or coping strategies. So I suppose one of the drawbacks of the adverse childhood experiences checklist is that it doesn't take into account-- it says whether or not you've experienced an adverse event, not necessarily about how you coped with that. And I wondered whether what the relationship is between coping strategies and trauma. Does having good coping strategies in the face of adversity reduce the likelihood of something becoming a traumatic event? So we did a really interesting study with frontline workers in homes who cared for children a few years ago. The study started off looking at the kind of workforce being of that really critical workforce who often do long shifts in really unique environment and often don't have the mechanisms of support that we might have as clinical psychologists in practise in terms of fairly regular psychological supervision, reflective practise spaces, and so on. Although, I think that is changing, which is great. But one of the things that we were looking at with them was when you're doing this really difficult job that brings in lots of stressors and can have a lot of unpredictability and can be quite challenging as well as very rewarding working environment, what kind of coping strategies are helpful. And as you might expect, we found that actually avoidant coping strategies were more likely to lead to perhaps experiences of burnout, compassion fatigue, whereas if people had coping strategies that supported their self-care practises and their overall being, their ability to ask for help, draw on supportive relationships, and then that was a real protective factor. And I think one of the things that we're hoping to do through our nest study at the moment in homes who cared for children is to try to understand from the young people's perspective, how can trauma responsive environments support young people to develop coping strategies that help them with some of those same challenges and difficulties, especially given the relational losses and trauma that so many people in care have experienced in their earlier life. And thinking about framing and how we frame certain experiences. I remember when we worked together, you were doing a study about young people who were hearing voices. And correct me if I'm wrong. But I think the takeaway from that work was it's a common experience amongst young people to hear voices. And it's not necessarily indicative of psychopathology. And I would take from that that if you frame hearing voices as a particularly problematic experience, and that might lead to worse outcomes than if you frame it as, oh, other people might also sometimes hear voices and this is not necessarily problematic. It's framing also part of the reason why there are individual differences in the impacts of trauma on mental health. There can be absolutely. And we've learned over the last couple of decades actually some things that can be incredibly unhelpful for people who've just experienced something really traumatic. So we know the outcomes are worse if, for example, someone is in a car accident and the first thing that they hear when they get out of that car is, what are you doing, what have you done. The insinuation of blame, we know, can be hugely detrimental to recovery and well being from people from that sort of situation. Similarly, in some contexts, this is a broad statement and there are lots of caveats to it. But we know that actually in some situations following a traumatic incident, actually, an immediate debriefing can be quite counterproductive and actually letting people make sense of it in their own time, form their own meaning making, and rely on their personal resources and coping strategies can be quite helpful. And I suppose particularly in terms of coping, going back to the study that you mentioned there, which was our young voices study. And we've had various interesting projects come out of that. We've got an intervention study running in CAMHS at the moment following that up, which is very coping strategy focused. It's very much about, OK, well, this is a common experience, but that doesn't mean that it's not really frightening sometimes or really upsetting or stressful. So what coping strategies are working for you currently? And here are some other coping strategies that young people can sometimes find helpful, and that parents can sometimes find helpful to use. Let's play around with them, explore them, see what works for you, and find those multi-sensory coping strategies for those multi-sensory distressing sensory experiences. So actually, a lot of our work has come back to focusing on what is already working for young people, what they've already found that works for them, and then trying to offer some additional alternatives, but with very much kind of current focus and coping strategy focus. And Sarah, I really enjoy your tone. You're a clinician, aren't you? Yeah, because I can hear that sort of acceptance and that phraseology, which is so-- I'm finding it very comforting listening to it. We can explore this, and we'll figure it out, and it will be OK. And that's a wonderful, the idea of it's that curiosity that's embedded in much of trauma-informed care, which is just imbued in your phraseology because that makes a young person feel safe. It's not that there's a wrong or a right way to cope. There's a way that works for me, and that's all right. And maybe I can make it even better with some support. And it's just lovely. It's a very important and really nuanced thing in terms of phraseology and the framing, which you've just described beautifully. There was a paper that you wrote. And it's sort of related to this point I'm jumping in here. But there was a paper you wrote about young people's experiences of talking therapy. And I think it was young people who'd been sexually abused. I think that's correct. Can you describe some of those findings? Because it sits that sort of that investigation was really interesting. Could you describe some of the findings? Because I think they sit well with what we're talking about. Sure, I can try. It was a long time ago. I think that was one of the reviews that I did when I was training, actually. Yeah. And I think actually, a lot of the findings from that review were very much in parallel with, I suppose, the things that we talk about in terms of-- I'm going to say trauma-informed care, but let's come back to that title in a bit. It was around offering choice and how choice can be empowering. When someone has been so disempowered, actually, any opportunity to offer choice to help that person think, well, what do I want, what's important to me, and what do I want to get out of this, I think, can be really, really important. I think thinking about the safety of the environment. So within that review, there were stories in there from survivors who had been involved in one to one talking to therapy, group talking therapies, some of which were peer led, some of which was facilitated by mental health practitioner. And I remember some of those stories quite critically reflecting on actually, if you're very anxious about being exposed to further trauma, when you're perhaps not quite ready through hearing about stories of others, actually, that can feel like quite a threatening space. Whereas if you're in a different space, and you're maybe a little bit further down the road in terms of making sense of your own experiences, it can be really validating to hear survival stories of other people who've perhaps have similar experiences. So to think about the importance of timing and when people are ready for what. And I think that's where getting to know somebody, understanding where they are at in terms of their relationship, what might have happened to them is really, really important in terms of them figuring out, OK, so this, that, and the other might be quite helpful in the future. But actually, right now, what will I need to do is focus on developing the supportive relationship with this young person, helping them to feel safe in the moment. And then we can work on the rest over time. But at the moment, that's the foundation that we need to build. I think the conversation that we've had so far is focused on the direct experiences of trauma that a young person might have. But there are indirect experiences of trauma that might impact upon the young person's mental health. So there's two that I can think of. First I think is intergenerational trauma. To be honest, let's unpack that term. What is intergenerational trauma? Because I've heard that term used. I'm not quite sure that I understand the lay use of it, the popular use of it. I don't know the scientific term and what it means. And then the other indirect trauma is when traumatic events happen in the world that, as a child, you might not be part of, but you see in the news, or you experienced-- you hear about it at school. And again, it's indirect form of trauma potentially. But what are the impacts of those indirect forms of trauma? I suppose, again, it comes back to what is the context of the young person when they're having that experience. And particularly, when we're thinking about types of trauma that might involve many people within that young person's family or system over time, we need to be thinking about what their bigger picture is, what are they seeing modelled. What are they seeing being experienced by others. And I think that's as well where if you think about what trauma can look like for different people, we know that there are certain experiences and events that can happen in a young person's like bullying or a bereavement, which can be hugely traumatic. And so often, it's whether or not that experience can be shared with others, supported by others that can really help in terms of that young person either feeling empowered and supported and to be able to build on support from other people around them. Or they might feel very silenced or blamed or criticised, in which case they can feel incredibly isolated in that experience and it can be much more difficult to process and take much longer to process. So whilst these terms can make us think of quite concrete times in someone's life, there's huge variety in terms of actually what those experiences can look like and feel like and the impact that those experiences might have on someone over time. And I think if we were to take something as massive as intergenerational trauma, again, that depends on are we looking at that perhaps in the context of domestic violence, are we looking at that in the context of people from racialized minorities. And if so, what's the wider cultural context within that, and how can that be impacting somebody in the here and now, depending on the culture that they're then within in terms of their family, their friendship groups, their school, their education, their neighbourhoods? There are so many factors to take into consideration there. So again, it kind of just brings us back to, well, what does that mean for the individual person, and what support, if any, do they feel as though they might like or that might be helpful to them in that time, in that moment. Are there parallels between cultural humility and trauma-informed informed care? In other words, it's making me really think about that individual experience and individual-- From a cultural context, and I'm an individual in that. And I take what makes sense to me, and I leave what doesn't. Would you say that there are parallels between cultural humility? Or perhaps it should be part of trauma informed care? Absolutely. So let's take the term trauma-informed care. You can be trauma-informed and not supported to be practicing in a trauma-informed way. You can be trauma-informed and feel as though it's not possible to work in a trauma-informed way, which can create a lot of conflict, I think, for practitioners sometimes. And they really want to work in a particular way. But perhaps, for whatever reason, they feel as though they've got the support or resources or other things to work in that position. If we change talking about trauma-informed to trauma-responsive, then we can be thinking about things in a much more active way. So if we are responding to an individual, we are recognising their unique context and what they need. So that might include trauma or traumas that they've experienced. It might be also thinking about their response to that trauma within the context of their identities, their intersectional experience of themselves, the people in the world around them. So I suppose in that sense, it becomes much easier to then think about, OK, well, what are the useful frameworks can we bring in to working in a trauma responsive way that truly responds to the individual needs of the person that we're working with as opposed to working in a more linear way of applying a set of principles or a set of practises uniformly. And I think that's perhaps where-- I know you mentioned, Jane, that some of these difficulties around working or talking about working with trauma-informed care way, what does it mean. And I think that obviously varies across different contexts and settings. But for an organisation, and the people that work within it, and the people who are supported by the organisation who experience a trauma-informed approach, it has to be completely integrated into all levels of that organisation your working. And that's, I think, perhaps where trauma-informed working has perhaps fallen down and where it's quite difficult to keep consistently practicing a trauma-informed care way. So I think perhaps if we can start to think more about, as many, many organisations are already doing, kind of working in a trauma responsive way, we can think, OK, well, what does that mean in terms of, perhaps as a supervisor, how could I support a colleague in a trauma responsive way, how could I support children and young people and their families in a trauma responsive way that's responsive to their needs. If an organisation is going through stress and feeling strained, what might the organisation or the people leading that organisation need in a trauma responsive way to support them, to maintain those trauma-informed principles across the different levels of the organisation? So I think in terms of the language that we use, we can think about being trauma aware, and that's really helpful. But I think there's perhaps less of an assumption that you're automatically working in a trauma-informed way if you're trauma aware. I think trauma-informed care is a term that's been around for a long time. And I think perhaps it has got a bit diluted in terms of what it means. We can keep coming back to those guiding principles. But I think with the current move towards trauma responsive care I think offers us a more active and engaged way of understanding what does this mean for the conversations we have, what does this mean for the care we deliver, what does this mean for how we understand people's challenges and difficulties and struggles. So I think that's perhaps where a lot of the language is moving. And that's really helpful to pull apart those because language matters. And what I was really struck by when you were describing those issues is the importance of the environment and the system that we're working in. So if I'm working in a trauma-informed way, or I want to be trauma responsive, I will need to have the same therapy room every time I see a young person. I need to get across that particular import to the administrative procedures that are in the building that I'm working in. And that is one of the challenges. So what happens in a room is one thing. But the environment which relies on a lot of non-therapeutic systems is another. And I think you're highlighting the dilemma and the challenge so well to think about the organisation and the systems as well as colleagues and extended issues. That's really helpful. And I'm mindful of the time. So now might be a good point to wrap it up there. That's been a really nice conversation, Sarah. I really like how, despite me being one of those people that's like, no, but what is it, what is it, being very flexible, subjective, all of those things which are really necessary because I think my mind works in a very binary way. And from this conversation, I've learned that that's just not how trauma works, and that's not how we need to conceptualise trauma. So thank you for that. And thank you for trying to encourage me to be a bit more broaden my thinking around these concepts. I think it's an interesting one, I suppose, especially around trauma or trauma-informed care, trauma responsive care, because I guess as a practitioner, if the premise that I'm arriving to something with is-- whatever has happened to somebody is their story, it's their truth, I'll need to understand how to understand it from their perspective. I think that clashes somewhat with my researcher hat on in terms of, OK, so what's the definition that we're working from? I think it can be quite helpful to sit somewhere between those two positions at least at the moment, because I think there is still so much that we don't know and that we need to work out. And in the spirit of working through a sort of trauma informed lens, these things take time. They take lots of different perspectives and voices to figure out. So in one of our studies at the moment, the [INAUDIBLE] study, we're all sort of keen to see what comes forward in terms of, OK, well, how can we conceptualise and define trauma responsive care in the unique context and settings of homes for cared for children, but still knowing that that's only going to be a kind of one part of the picture. And then we're still going to have to explore that further with individual people to try to develop a much more nuanced and collective kind of understanding, really, of what that means in that unique environment. So yeah, it's never straightforward, is it? But I think the more we can sit somewhere in the middle of exploring and looking to find out and trying to understand something from the theory and knowledge that we have so far I think can be quite helpful. Absolutely. And that's a nice point to end on there. It's like a compromise. Neither extreme is probably helpful, but meeting somewhere in between is the way forward. Thank you so much, Sarah, for that really nice conversation. So thank you so much for joining us. Thank you. Thanks for having me. What a great conversation with Sarah. It's always nice to have clinical people in who also do research because then you get the best of both. And I think that we've really seen that with Sarah. Particularly, Sarah not committing to this black and white yes or no, it is or it isn't trauma definition because as a researcher, as a quantitative researcher, I'm very committed to that idea. You either experienced an adverse childhood experience or you didn't. You either experience a traumatic event or you didn't. And this is a very different way of thinking about those things. And I mean, I really enjoyed her turn of phrase as well. I could feel her move into a clinical phraseology. And also, her requirement to be systematic and identify particular outcomes was really interesting. And holding both of those positions was very important. I mean, we talked quite a lot about the phrases, the words we might use for trauma-informed care or trauma responsive care. But we didn't get a chance to look at the literature in much depth. And actually, there is a good systematic review looking at the evidence-base for trauma-informed care, and there is a good evidence-base to show that it is effective. So Zhang and his colleagues looked at outcome measures like PTSD or behavioural disturbance. And they found medium effect size where a trauma-informed care package was applied. The problem was-- and this really comes back, Umar, to what you were saying is what is it, can you describe what it is. And actually, it's quite difficult to pin down what it is. There's no manualized treatment protocol. It's a sort of state of mind or a contextual approach. And that means that there's such a lot of variability in the delivery that it's hard to capture what we're delivering. So I think you were right to say yes, I want to know exactly what it means. And also, that's an impossible task. And maybe that's not a bad thing. I think that's a good thing because I think there are-- obviously, there are benefits to something becoming manualized. But there are real drawbacks to something becoming manualized because like you say, it's not just something that you do, it's something that it's part of the wider system. And when Sarah was talking about this, I was thinking about whole school approaches to mental health. So the idea there is it's not just one person's responsibility or the safeguarding team or the welfare officer at school who's responsible for the young person's mental health. If we have a whole school approach, it's everyone. It's the child themselves, it's the parents, the teachers, the TAs, the receptionist, the cleaners, the canteen people, the headteacher, senior management. Everyone is involved. And it's about the school ethos and the approach to mental health and all of those things. And it seems to me that, when we're talking about trauma informed care or trauma in general, I think that that's the kind of approach that Sarah was trying to get at. It's not something that you as an individual do. It's about how we think about these things as a system. And whatever that system is, it could be a school system, a home system, whatever. Tertiary care system, I think it is now. Yeah. And I mean, it's such an important thing, an important problem to establish because it's so systemically embedded. And it does mean that the challenge for changing that is bigger. But we have to know the size of the storm before we can put our rain gear on. And that is really powerful. I think Sarah did talk about that tension. And I certainly could recognise that in my own clinical work. If you need a consistency in terms of the setting, I just need the same room every time this young person comes to the clinic. And I can't guarantee that. And so that tiny piece of delivery makes a difference to that young person. And it has enormous implications for the work we're going to do in that room together. And it's something that I can't fix as an individual. So it's really powerful. Just to come back to the trauma responsive care, I think it's interesting because when I was looking at the NICE guidelines, there was no discussion of this phrase in particular. But what they listed in terms of the guidelines would certainly be recognised as a trauma-informed piece of work. So thinking about the whole culture, the experiences, environmental factors, and relationships with professionals. So it was interesting. I wondered why they didn't use that phrase. And it did make me come back to that idea that sometimes it's used a bit glibly rather than embedded in day to day experiences. But yeah, it's a really interesting conversation. I enjoyed it. So takeaways, takeaways, takeaways. For me, it's that, as a quantitative researcher, I need to think about more than just the presence or absence of something that I'm trying to measure and think about the young person's experience of that. And I think in the bullying literature, in the previous department that I worked in, somebody bullying research, and they were all about appraisals. So it's how do young people appraise and think about the experience of them being bullied and how does that impact upon their outcomes. And I think that is a step in that direction. So it's not just whether or not an experience happened. It's how they've experienced the experience. Yeah, absolutely. You hit the nail on the head. I think there are four things I took away from looking at that literature-- the invitation to look at the literature. And one is when we're thinking about ACEs and trauma is that they cluster. So when you have one, you're more likely to have another. The second is the more you have, the likelihood the greater the impact is, but the idea that trauma is modifiable. So with that trauma responsive care, we can change outcome. But the bottom line of the takeaway is that it's highly individual, exactly as you were saying. And so that really comes back to the idea that it really is all about me.