David Trickey Hello, my name is David Trickey.  I’m a Consultant Clinical Psychologist, and   Co-Director of the UK Trauma Council. I’ve been  specialising in working with traumatised children,   young people and their families for over 20 years,  and what I’d like to do in this presentation is   speak with you about what it is that makes an  event traumatic. So, many children, young people   and families will experience difficult or adverse  events, but what is that makes one of those events   actually traumatic for them? And I’m going to  use a particular psychological theory, and then,   of course, we’ll also think about what can we  do to help to reduce the impact of those events? And before I do this, just check in with yourself,  you know, I don’t know what’s happened in your   past, or what’s going on for you now, but I  do know that we’ll be talking about trauma,   and as nice human beings, as compassionate people,  we should be moved when we think about trauma.   But if, for whatever reason, you start to have  stronger emotional reactions than you’re happy   with, or you start to feel overwhelmed, please  do take responsibility for yourself to look   after yourself. Do what you need to do, whether  that’s step away and do this on another day,   or perhaps think things through before you  move onto whatever your next activity is. I just wanted to say a little bit about the  UK Trauma Council. This is a project where   we try to create resources to help those of  us doing the direct work with young people,   or those around the young people, so that we  can help them have the best chance possible of   recovering from any events that they’ve  experienced. So, our focus is on those   people around them, whether that’s Social  Workers, or Foster Carers, or Therapists,   or Teachers, we try to guide policy, so that  those making policy decisions can make well   informed decisions and, mainly, we provide a lot  of free and accessible resources and guidance. We don’t just make these ideas up. We  draw very much on the research evidence,   and we work very closely with the intended  audience, whether that’s young people themselves,   or Foster Carers or Teachers. We have a  group of child trauma experts from around   the United Kingdom, and we also work  closely with our Youth Advisory Board,   which is made up of young people  with lived experience of trauma. The sorts of resources that we’ve produced  recently include things such as Childhood Trauma,   the Brain and the Social World, but really  tries to explain how a young person’s brain   adapts to their experience and how that  might cause problems later on. We’ve got   some resources on Traumatic Bereavement aimed at  schools and Clinicians. We have some resources   about Childhood Trauma and PTSD, that includes  some animations written with young people,   aimed for young people, to help them  understand what PTSD is and what might   help. We have resources for schools and  colleges and other educational communities,   thinking about critical incidents and how they  can provide the best environment for recovery. We also have resources on Childhood Trauma, War,   Migration and Asylum. This includes an  animation aimed at young people to help   them really understand how their traumatic  past might be impacting on them, and what   can they do to move forwards with that. We also  have resources there for schools and community   organisations, helping them to work out how can  they best assist young people seeking asylum. We’ve got a couple of policy guides  for people making policy decisions,   and we also have a whole group of resources to  really help people put research into practice.   This would include short explainer videos, regular  roundups of the research and, occasionally,   we will do a topic-based research roundup. We  have one on Racism, Mental Health and Trauma,   really trying to understand, what does the  evidence tell us about this topic? And,   also, more recently, we’ve produced one on  Developmental Trauma Disorder. So what does   the evidence say about this as a topic and is  this useful, you know, what do we know about it? So, before we think about how a potentially  traumatic event might affect people, let’s   think about how many young people would experience  difficult events. So, here’s 100 young people, in   reality, in my experience is they don’t normally  line up quite as uniformly as that. So here’s   100 young people, and if we stick to the DSM-5  definition of trauma for post-traumatic stress   disorder, that would be “actual or threatened  death, serious injury, or sexual violence,” and,   in fact, what we find is about a third, 31% of  them – this is taken from a research study in   England and Wales, would be exposed to that  type of event by the time they get to 18. But that’s quite a high bar, that’s a  very specific definition of trauma. But   if we broaden our definition of a potentially  traumatic event to include being threatened,   hit or hurt badly, or coerced or forced  sexual activity, or bullying, both in-person,   but also online, then actually we see  many more young people will have been   exposed to those sorts of events. Up  to about 83% in one study in the UK. Now, how do we define trauma? Well, the  UK Trauma Council would suggest that   trauma is “an experience or experiences  that overwhelm one’s ability to cope,   resulting in enduring and negative reactions.”  So, these are not just difficult, distressing   events that lead to temporary upset or  problems. These are things that overwhelm   someone’s capacity to cope, and actually leads  to something that’s going to last some time. And you could think about different trajectories  or paths if you want to. There’ll be some people   who’ve experienced a potentially traumatic  event, and actually seem pretty unaffected;   they seem to sail through it. There’ll be  some where they experience traumatic events,   but then they seem to do okay, but then  later on, they start to develop problems.   There’ll be some that develop difficulties or  distress and these last and endure over time,   and there’ll be a big chunk of young people  that would experience potentially traumatic   events and they start off struggling,  they may have a lot of distress or a   lot of difficulties, but over time,  in fact, they recover spontaneously. And what I really want to do is think with you  about what is it that makes that distress and   those difficulties last? What are the mechanisms  behind what’s going on for the young person,   that mean that the difficulties will last over  time? And one way that we can think about those   mechanisms is to think about the Cognitive  Model of Post-Traumatic Stress Disorder,   or PTSD. And this doesn’t just explain reactions  that result in PTSD, it actually, I think,   helps us to understand how potentially  traumatic events affect a young person,   and all sorts of different  reactions that they may have. And the model is based broadly on two  papers about adult trauma and PTSD,   and Meiser-Stedman weaved these two approaches  together and thought specifically about   children and young people. And the story  goes, because a model is just a story,   that if you are traumatised by an event,  if you have a lasting, negative reaction,   and it might be because of the memories you  have for those events, or it might be because   of the meaning that you give to those events,  and often those two things will work together,   memory and meaning, and then the difficulties  are maintained usually by a process of avoidance. I don’t know if this model is truthful. I don’t  know if this is what really happens in the minds   of children and young people following potentially  traumatic events, but I do know that it’s useful,   because it helps us understand how  people react to traumatic events,   not just PTSD. It helps us understand why  some people will struggle and others don’t,   so all of the risk factors that increase  the likelihood of difficulties. It helps   us understand what we should be  looking for in our assessments,   and helps us understand why some approaches to  support an intervention seem to be effective. So, let’s think about the memory bit of this  story first. Have you ever had that experience   where you’re walking along the road and a memory  suddenly falls into your consciousness? You didn’t   fetch it on purpose, but perhaps something in your  environment triggered it and, suddenly, there it   is. Now, most of us have had that experience  at some point, but most of us don’t have it   most of the time, because it would be chaos. We  wouldn’t be able to function if our memories just   kept falling into our consciousness. So, we seem  to have developed a preference for keeping our   memories at bay until we need them, then when  we’re finished with them, we put them back. And I was explaining this to a 14-year-old many  years ago, I was talking about evolution. I said,   “If you’re running away from a dinosaur  and you just keep remembering everything,   you’ll get eaten. You’ll be running away and  you’ll be thinking, oh, do you remember that game   of football we had down there, do you remember  that picnic we had up there?” Those people would   be distracted and not survive. The people that  could put their memories to one side and run,   they would be the people that survive and  have children with similar sorts of brains. This was my description of evolution, and  I’m very lucky that I work with some very   patient 14-year-olds, and she said, “That’s an  interesting story, but I’ve got two problems with   it. The first is that humans and dinosaurs didn’t  exist at the same time,” which was news to me,   and she said, “and, anyway, I believe that  God made us like this.” And I said, “Well,   didn’t he do a good job,” because whatever story  you have, broadly speaking, we know that our   memories for normal events will stay put until  we need them. So, if I asked you about the last   time you went to the cinema, you would locate your  cinema memory, bring it into your consciousness,   tell us the story of going to the cinema, and  then we’d move on and you’d put that memory away. Now, Professor Brewin calls these “contextualised  representations,” or “C-reps,” these are memories   for normal events. And we know quite a lot about  these normal event memories. We know that they   consist of words and stories, so when I tell you  that story of that young person I worked with,   I don’t remember the data of the event. I  don’t remember what time of year it was,   how cold it was. I don’t remember the sound  of her voice or what room we were in. What I   remember is the narrative, the story, that’s the  bit that comes into mind when I tell the story. And normal event memories are pretty coherent  and complete, so they don’t tend to have gaps,   and if they do, we may well fill those  gaps in, and they, sort of, make sense,   and they stay put until deliberately recalled.  So, I deliberately bring that story to mind,   tell you the story and then put it back, I’m not  going to be thinking about that event later on   today. I mean, I roughly know when normal events  happened, back there and back then, and they   might change over time. Our memories are pretty  unreliable in some ways, and any original emotion   will often fade from the event, and they tend to  be linked to other memories, and they’re welcomed,   or at least tolerated, even if they’re unpleasant  events, we can normally tolerate the memory. But at times of extreme horror, or  helplessness, or shame, or pain,   or terror, then, actually, at those moments,  we’re in a different mode and, as a result,   memories for those events get stored in  a different format. They get stored as   the vivid data of the events, the sights, the  sounds, the smells, the tastes, the touches,   the pain, the feelings, and the thoughts. And  memories for those events tend to be fragmented   or jumbled. They don’t have that smooth coherent  narrative. They have this moment and that moment. And they tend to be very volatile. They’re very  easily triggered, or they might just have a bit   of a mind of their own and intrude into our  consciousness. And when they come to mind,   doesn’t feel like it was back there and back  then, it might feel like it was just yesterday,   or even here again now. These memories tend to be  locked in, they don’t tend to change over time,   and the original distress is activated often at  the same intensity of the actual event. And they   tend to be isolated from other memories  and, of course, they tend to be avoided. Brewin would call these “sensory bound  representations,” and they fall into   consciousness, we don’t like that, so we push them  away. And because we push them away, we don’t get   to store them in the same way. And then people  get stuck in an internal avoidance trap, so you   might think of this as a maintenance cycle, this  unprocessed memory intrudes into consciousness,   that’s its nature, bringing with it the original  fear or horror or helplessness, and, of course,   people try not to think about it. They try to  suppress those memories. But because they don’t   think it through, they don’t get to  process the memory and change its format,   and then that very act of avoidance actually  triggers the thing people are trying to forget. And people also get stuck in an external  avoidance trap, where these unprocessed   memories are very easily triggered, which is  really unpleasant. So, people avoid triggers,   they avoid places, people, activities,  that might trigger those memories. And   that means they don’t have that chance to  think it through again. If you went down   the same street where something awful had  happened, you’d probably be thinking, well,   this happened and that happened and that happened,  it’s a way of processing what happened, but,   understandably, you avoid it, so you don’t  get that chance to think it through. But,   again, that act of avoidance actually triggers the  thing you’re trying to avoid. One boy said to me,   “It’s like a boomerang, the harder I throw it  away, the harder it comes back and hits me.” I don’t think that this is a brand new  discovery or invention of two different   memory systems. Pierre Janet, more than 100  years ago, was talking about the same sorts   of phenomenon. He was talking about fixed ideas  of traumatic events rather than usual memories,   and people can’t make the recital, they can’t  tell the story, which is what we would think   of as a normal memory, and yet they remain  confronted by it. So, it’s a very old idea. Now, interestingly, there’s a questionnaire called  the “Trauma Memory Quality Questionnaire,” and   this assesses the number of aspects of a memory  that are characteristic of traumatic memories. So,   for example, it says, “I can’t seem to put  the frightening event into words,” and the   young person rates how much they agree with that  statement. “I remember the frightening event as   a few moments, and each moment is a picture.” And  what’s really interesting is the higher your score   on this questionnaire, the more likely you are to  have PTSD, and the worse your PTSD seems to be. And you can do that even longitudinally, so  you can predict someone’s later PTSD based on   an earlier score on this questionnaire. Now,  to me, this really supports the idea there’s   something about the quality of the memory that  is driving distress, particularly PTSD symptoms. And just as another way to illustrate this point,  there was a study a little while ago where adults   with post-traumatic stress disorder were in  a br – put in a brain scanner and different   types of memories were deliberately triggered.  And once they’d done this quite a few times,   including the traumatic memories, they could  see which parts of the brain are only activated   by certain memories. And what they found  was that Broca’s area, one of the language   centres of the brain, is only activated by  neutral memories, not by trauma memories. So, they’d be lying in the brain scanner, and the  Researcher would be prompting different memories,   “Do you remember the time you went to the  cinema?” Broca’s area comes online. “Do you   remember the time you went shopping?” Broca’s  area comes online. “Do you remember the time   you were sexually assaulted?” Broca’s area  doesn’t come online. So, when we sometimes say,   “Some events are too terrible for words,”  in a way, that’s what this brain scan shows. And then they also found that there were  various parts of the brain that were only   activated by the trauma memories, not  by neutral memories, and in particular,   the amygdala, which you might think  of as the alarm centre of the brain,   is only activated when those trauma  memories are brought to mind. So, again,   we see more support here for the idea that we  have these two different types of memory systems. So, how do we explain this to children,  young people and families? Well,   we have a number of stories. The first story is  about a chocolate factory. The chocolate factory   takes the ingredients, the sugar, the milk, the  cocoa, mixes them up and creates a chocolate bar,   and then puts a wrapper around it. And on  the wrapper, you have words on the outside   that tells you what’s on the inside, it says,  “Ingredients,” and it lists the ingredients.   And in some ways our brains are similar.  We take the sights, the smells, the tastes,   the touches of an experience, and we create a  memory, and then we wrap it up with a narrative,   so you have words on the outside that tells you  about the contents, about what’s on the inside. But with the chocolate factory, if the sugar  was not ground down enough, it’s too lumpy,   or if the milk was too hot, the machinery would  not be able to cope with those ingredients. It   wouldn’t be able to mix them together, and it  would grind to a halt, and you’d end up with the   ingredients swilling around on the factory floor.  And, similarly, if we experience an event that is   overwhelming, that we can’t cope with, that we  can’t process, then we end up with the elements   of that experience, the sights, the smells, the  tastes, the touches, swilling around in our minds. So, with a chocolate factory, you might get  someone into help, you might just wait until   the milk is cooled down, or you might need to take  the sugar and grind it down into smaller pieces,   and then you can start to mix the ingredients  and create your chocolate bars. And, similarly,   with potentially traumatic events, you might  get someone to help you think it through. You   might just wait until it’s less frightening,  or you might need to take those experiences   and break them down into smaller pieces, and  then you can start to process your memories. And the next story we tell is about a  wardrobe. So, if you imagine a wardrobe,   you have all your clothes put away, when you  need them you take them out, wash them – wear   them and wash them, very occasionally  iron them, and then you put them back,   and they can stay put, and you close the  door and get on with life. And, similarly,   you have all your different memories stored  away, when you need them, you bring them out,   when you’re finished with them, you put  them back, and they pretty much stay put. But with the wardrobe, if someone threw you  a duvet and it was full of stinging nettles   and they said, “Put it away quick,” and  you shove it in the back of the wardrobe,   and it hurts to hold onto it, so you’re really  trying to get rid of it, but it’s not put away   properly, and it keeps bulging out. And if you  keep your hand on the door and keep it closed,   it might stay put, but every time you take your  hand off it falls out and it hurts you again,   and you have to shove it back in the wardrobe. And, similarly, if you experience a potentially  traumatic event, you might try really hard not   to think about it and shove it in the back of  your mind, and if you keep yourself really busy   it might stay there. But perhaps between going  to bed and going to sleep, or other moments when   you least expect it, it’ll fall back into your  consciousness and hurt you again, and you try not   to think about it, you’re trying to shove it back.  So with the wardrobe and the duvet, you might get   something to help you. You need to take hold of  it, which might be painful, you need to fold it   up neatly, you might have to move things around  on your shelves, then you can put it away, and   it’ll stay put. And, similarly, with potentially  traumatic events, you might get someone in to help   you, you need to take hold of that memory and  think it through. You might have to adjust the   way you see yourself, the world, and others, but  then you can put it away, and then it’ll stay put. I was explaining this to another very patient  14-year-old a few years ago, and I was explaining   why I thought it might be a good idea to do some  more trauma-focused work, where we deliberately   think about what had happened to him. And I told  him these two stories, and he said, “It’s a bit   like that, David, but, actually, it’s more like  this.” And he got the wastepaper bin, and he put   it on the desk, and he filled it up with scrunched  up pieces of paper, and he said, “These are all   the bad things that have happened to me, and as I  walk to school, they fall in front of my eyes, and   when I lie down and go to bed, they fall into my  dreams. And when I come and see you, we take them   out of the bin and we unscrunch them, then we read  them through carefully and we fold them up neatly   and we put them back in the bin. But because  they’re folded up neatly, it means they don’t   fall out of the top, and I’ve got more room in my  head to think about other things.” And I was sat   there with my notes going, “What’s that  last bit about more room in your head?” And then more recently, I was working with a  young boy who had experienced something awful,   and he kept having these flashbacks, where he  could re-feel the sensations of what had happened,   and he really wanted them to stop, and  he really didn’t want to talk or think   about what had happened. And I just wanted to  sow the seed of the idea that at some point,   with somebody, it might be useful  to think these things through. And I told him some of these stories,  and halfway through one of them,   he closed his eyes and put his hands up to his  head. I said, “Are you okay?” He said, “Yeah,   yeah,” he said, “I think I’ve got it, is it like  this? On my laptop I’ve got a load of jpeg files,   some of them are corrupted, the rest are  massive files, they take up loads of room,   and they keep making things crash. Are you saying  if I take the jpegs of what happened to me,   and I write them out and I save them as a Word  document on my hard drive, then that will stop   making things crash?” And I said, “Yeah,  that’s exactly what we’re talking about,   we’re going to change the format of the file. We  can’t delete it, but we can change the format,   and that will mean that it behaves differently.”  So, that’s the memory bit of the story. If we now think about the meaning bit,  broadly speaking, we have different thoughts,   different beliefs, different assumptions,  about the way that things are supposed   to work. We have assumptions about ourselves  being, kind of, nice enough and worthy enough   and loveable enough. We have assumptions about  the world being benevolent, broadly speaking,   and making sense, and for most of us it’s safe  enough. We have assumptions about other people   being trustworthy and worth relating to and  these assumptions are very much unconscious   most of the time. They’re unarticulated,  we just behave as if they were true. And you could think about those assumptions and  beliefs as a lens that colours the way that we   see things, and it will lead to certain thoughts  and feelings and actions. And, broadly speaking,   the way that we perceive things will  very often strengthen our beliefs,   because that lens can act as a filter,  that filters out anything that doesn’t fit,   or it can twist and distort things so  that it does fit, ‘cause we prefer to   hold onto these assumptions, rather than  change them each time something happens. But if something comes along that is too big  to ignore and we can’t explain it away, well,   then it does change the way that we see things,  and we end up with a new set of beliefs, a new   set of assumptions, about ourself, the world,  and others, and even when that event has passed,   we’re now left with a different way of seeing  things. And then we see the world differently,   we see people, ourselves, the world,  in a different way, a different lens,   and then we have different thoughts, different  feelings, and different actions. And, again,   our actions and our perception may well  strengthen our trauma-based beliefs,   and I’m going to give some examples in a  moment that will show what I mean by this. [Pause] But before I do that, let’s just think  about multiple events. So, it’s one thing to think   if you have an okay view of yourself, the world  and others, then a single event comes along and   shatters those assumptions, but what about if  it’s just one thing after another? But I still   think the model is helpful, it’s just that our  beliefs build up over time, based on repeated   events. And then if those events stop, then  actually we’re left with a different – or with   a really particular view of the world, and  that then colours the way that we see things. And the sorts of beliefs and thoughts that  people might have, it might be about themselves,   thinking that they’re useless, or that they’re  weak and fragile, or that event has now made them   believe that they deserve bad things to happen to  them, or that they are unlovable. They mi – may   start to see the world as being completely  unpredictable, you never know what’s going to   happen next, or they might think that everywhere  is dangerous. Not just that street at that moment,   but actually the whole world is now dangerous, and  they might think that nothing makes sense anymore. They might start to believe that  other people can’t be trusted,   or other people are going to hurt them, or  people they love aren’t going to stay around.   They may have specific thoughts about the events  themselves and believe that they are their fault,   or they should have stopped them in some way.  And sometimes those – these beliefs and thoughts   will carry on, and it’s those things, this meaning  that they’ve made, that causes the problems. And there’s another questionnaire called the  “Child Post-Traumatic Cognitions Inventory,”   that has 25 very bold statements. “Anyone could  hurt me, you never know what’s going to happen   next,” and the young person rates how much  they agree with these different statements.   What’s interesting is the higher your score on  this questionnaire, the more likely you are to   have PTSD and the worse your PTSD tends to be.  And, again, this seems to be a sound finding,   even longitudinally, so you can predict  someone’s future PTSD symptoms based on   their earlier post-traumatic cognitions. So,  this really supports the idea there’s something   about the meaning-making that is really  driving the distress and the difficulties. Now, you may be thinking, this only  really applies to single event trauma   for young people who are, kind of,  in an otherwise stable situation.   That’s just not true. There’s some really nice  research by Rachel Hiller, where she looked at   children in care, and she found about a third  of them had probable PTSD; this didn’t change   over the year. But what was really interesting is  their severity of PTSD and also complex features   of PTSD were not associated with how big or  bad their trauma was, with the severity of   their maltreatment, nor was it associated with  how old they were when they went into care. What she found was that their PTSD  symptoms, their distress, was associated   with unbalanced and unhelpful meaning-making. The  meaning-making was predictive of their symptoms,   and avoidant coping and the quality of the  memory. So, this idea of memory-meaning   and maintenance seems to hold true in predicting  distress, even in quite complicated populations. And I would suggest that it also helps us to  understand the reactions of a system around   the young person, it might be the families  and the carers, it might be the school,   it might be other professionals. Because, in  fact, if you have a belief about the world   being safe enough to let your child go off and  play, or to let your child go off with someone,   and then something happens to shatter that belief,  that assumption, it makes sense that you would   then be very protective or very controlling,  because you now don’t know who you can trust.   Or if you used to think that you could trust  yourself to make good decisions about who is   trustworthy and then that something awful  happens, then you end up thinking, well,   I don’t know who I can trust. I can’t even  trust myself to make good decisions anymore. So, again, for me as a Clinician, I might be  working with a family who are very protective,   and really want to get involved in the therapy,  and don’t really want to leave their young person   with me. Or you might have a system that feels  completely overwhelmed. They used to think   that they were good enough at what they did,  something awful happens, and now they think,   well, I obviously just can’t do this, so  they back off, they don’t even bother trying. You might have a system that believes they  might make it worse if you talk about it,   so we don’t talk about it at all, and they – it’s  the system that’s avoiding the conversations about   the event, and not just the young person.  Or you might get a family or a school or   an organisation that becomes preoccupied with  it, and is just always thinking it through,   trying to make sense of it. But what  often happens then is that they just   keep going over the worst bits, without  creating that complete, coherent narrative.  Now, so what? Really important question.  We have this model that seems to stand up   to scrutiny for explaining how trauma works.  Well, what are we going to do about it? Well,   if we’re talking about post-traumatic  stress disorder, PTSD, then, actually,   the interventions based on this model, normally  the trauma-focused CBT interventions, they seem   to work pretty well. We’ve got some pretty strong  evidence that this will work, not for everyone   with PTSD, but for quite a few children and  young people. So, if they do actually have PTSD,   we need to make sure that they are being  offered the right evidence-based intervention. But what about other problems, other than PTSD,  if we think about anxiety or depression or   aggressive behaviour? Well, I think this model  will also help us to understand some of those   reactions. I worked with a girl once, she was  about nine years old, she’d been abused by both   of her biological parents, and that coloured  the way that she saw things. She started to see   the whole world as unsafe, that other people  were dangerous. She would say, “particularly   those who are supposed to look after you,” and  she started to believe that she was unlovable. She said to me in therapy that if it had just been  one of her parents, it might have been about them,   but it was both of them, so it must be about her.  And eventually she was removed from her biological   parents and she landed in this amazing foster  placement. And the Social Worker said to me,   “Yeah, I know that she was – she’d been abused,  but she’s now in this amazing foster placement,   why hasn’t that repaired her view of the  world? Why hasn’t that helped her to recover?” And I think the model helps us to understand  why that might be, because these lovely,   lovely Foster Carers would approach her,  try and love her, try and care for her,   but she would see that care through her  particular lens, and she would think,   they’re going to hurt me, that’s why they’re  trying to get close to me. She said to me,   “They don’t love me, she’s just doing it for the  money, and he’s going to hurt me sometime.” So,   she would be very fearful and suspicious,  very, kind of, hypervigilant and hyped up.   She would lash out to keep them away from her,  kicking and biting, and very sadly, eventually,   the foster placement broke down, just confirming  her view of herself, the world and others. So, the other thing she said in therapy was that  sometimes in her foster placement, the memory of   her abuse would intrude, would remind her not to  trust other people. So, here we see the memory and   the meaning working together and, of course,  also, when those traumatic memories intrude,   they’re very upsetting and would lead to quite  a strong physiological reaction, as well. So, if we wanted to help Sue, it might be that  just a normal anxiety intervention, or working   just with the attachment might not work, because  she’s constantly got this memory reminding her   not to trust people. So, to really help her, we  might need to help her to reconsider her past,   to recalibrate the meaning and iron out the  memory, to really process through her memories. What about aggressive behaviour? I work  with one boy who experienced quite a   lot of domestic violence. His stepfather  would come home, hurt his mum many times,   and sometimes hurt John and his little sister.  And this repeated domestic violence led him   to see the world in a certain way, of course.  He started to believe that he was vulnerable,   that the world was dangerous, and  that other people are violent.   And eventually when the mum was able to  leave the stepdad, so they were now safe,   he was left with this view of himself, the world  and others, this was the legacy of his trauma. And one day he was in the classroom and the  Teacher raised his voice in the classroom,   but the Teacher happened to be walking between  the desks as he did that, and he happened to be   holding his finger up, and he happened to catch  John’s eye. And John, given his history, thought   to himself, here comes an angry, adult male, and I  know what they do, I know what adult males do when   they’re angry. So, he had what some people call an  amygdala hijack, and he lashed out at the Teacher.   He said to me later, “I just felt I had to do it  to him before he did it to me.” And the Teacher   was somewhat surprised to be attacked, he, kind  of, wrestled John off, tried to get him off him,   which John then saw as more of an assault. He  said, “See, I said he was going to attack me.” So, this whole incident just confirmed  John’s idea about the world being unsafe,   about him being vulnerable, about people,  particularly adult males, being violent. And,   again, when I was working with him, he was  able to tell me that there was something   about this Teacher in particular that would  really trigger memories of his domestic   violence. He said, “There’s something about  the way he would raise an eyebrow that would   just make me think about my stepdad.” And,  again, of course, when those traumatic   memories were intruding, that would lead  to a very strong physiological reaction. So, how do we help John? Based on this model,  what are we going to do? Are we going to teach   him some relaxation strategies? Yeah, maybe,  but, actually, if we really want to help him,   maybe we need to help those around him  to understand a bit more about trauma,   to understand the way that trauma affects  children and young people, and that, yeah, it   may look like they’re angry, but, actually, what  it is, is they’re just on a high level of alert,   and they see threat where the rest of us don’t see  it. So, maybe we need to help those around John to   see his behaviour, his actions, differently, to  make different meaning of what it is that John’s   doing. And then maybe we need to work with John,  to help him again recalibrate his beliefs about   himself, the world and others, and to do something  with those memories so that they stop intruding. What about traumatic bereavement, where there’s  something about the traumatic nature of the death   that is getting in the way of grieving the  loss? I worked with one boy where a number   of his family members had been ill during the  pandemic, and eventually a grandparent died. So,   these events really helped Omar to see the  world as being dangerous, I mean, there was   plenty of information around about how dangerous  the world was, that he was vulnerable, his whole   family seemed to be particularly susceptible, and  that others can’t be trusted. There was something   in the story about perhaps the Doctors hadn’t  done all they could to help Omar’s grandfather. So, when that event had passed, he was left  with this particular view of the world,   and when other schools were opening and pupils  were returning to school, Omar would see that   through his particular lens, and he would  think, well, I’ll get it if I go out there,   and I’ll die, or, I will infect other people. So,  that, of course, would make him pretty terrified,   he had strong panic reactions and, of course,  in order to keep him and his family safe,   he refused to return to school. He avoided his  friends, and he became increasingly isolated.   He hardly ever left the house. He stayed in his  room most of the time, and he certainly hardly   ever left the house. And this just maintained his  unbalanced beliefs about how safe the world was.   Now, of course, I’m not saying that the whole  world is completely safe all of the time, but,   for Omar, he overestimated how dangerous the  world was and just would not leave the house. There were also some traumatic memories of the  death of his grandfather. He remembered very   vividly the Paramedics coming up the stairs to  get granddad, and he remembers the footsteps going   up the stairs. He also imagined what it must  have been like for his granddad when he died,   and those images kept intruding and kept  reminding him of how dangerous the world was. So, if you want to help Omar with his  bereavement, to grieve the loss of his granddad,   you really need to help him to process the event  of the death first, so then he can bring to mind   all his memories of his granddad, and, yeah, of  course, be sad and grieve the loss, and develop   an ongoing connection. But initially, the only  memories that Omar really had of his granddad   were of his death, so if he can process those,  then he can start to access some other memories. What about low mood? How does  this model help us understand   low mood? One of the girls I work with had  experienced quite extreme domestic violence,   and eventually her father had killed her mother.  And she said to me, “Well, it’s my fault,” I said,   “Oh, that’s an interesting idea.” She said, “Well,  I gave dad the key, which meant he could get into   the house and kill my mum. If I hadn’t given him  the key, he wouldn’t have killed her and she’d be   alive.” I said, “That’s a really interesting idea,  have you ever told anyone else that’s what you   think?” She said, “I used to, but they said I was  stupid for thinking that and I should stop it.” And sometimes, in order to hold onto the idea  that the world makes sense, we end up creating   a story that says it was our fault, because if the  world is completely unpredictable and irrational,   that’s terrifying. But as a young person seeks  for meaning, “Well, why did that happen? Maybe it   happened because I gave him the key, maybe it’s my  fault.” So, actually, the world makes sense now,   this is why it happened, but there’s a price  that the young person pays for that. So,   whenever she was reminded of what had happened,  she would think, it’s my fault, I didn’t stop him,   and that was such an overwhelmingly awful  feeling and thought to have, that she would   push it away. She stopped going out, she stopped  talking about it, and, particularly, she stopped   thinking about it. And that means she didn’t have  the chance to recalibrate her responsibility more   realistically. She would think, it’s my  fault, that’s awful, and push it away. So, what I did, through our therapy sessions,  was I was just really curious. I didn’t challenge   her idea that it was her fault, I just wanted to  know more. I said, “Oh, that’s interesting, tell   me more.” And she said that she had previously  told her granny, but she – her granny had said,   “Stop thinking about it and don’t think about  it anymore,” which just meant she didn’t talk   about it with anyone. But through a number  of sessions of just exploring, saying, “Oh,   tell me more, help me to understand  that,” her story started to change,   and her story went from, “If I hadn’t given  him the key, he wouldn’t have killed her,” to,   “If I hadn’t given him the key, he  wouldn’t have killed her that night,   but he would have killed her another night.” And,  as a result, her guilt went from this to this. Now, Winnie-the-Pooh says, “A thing when  it’s inside your head seems very thingish.   When it’s outside your head, it  has other people looking at it,   doesn’t seem to thingish anymore.” And she also  had these sensory bound representation memories,   these trauma memories, that would intrude  sometimes, and remind her of what had   happened. So it was also important that we  sometimes did some work on those memories. And as she became more and more withdrawn, she  had less contact with her friends, and that meant   that she became more low and had less energy to  do things, and less opportunities to do things,   so she really got stuck in a low mood cycle.  But without going back and helping her to   re-evaluate her guilt, I think it would have  been really difficult to have actually helped   her to get out and see things differently. So, just to summarise, the Cognitive Model   of PTSD may be a really useful way to think about  the impact of traumatic events, not just when we   think about post-traumatic stress disorder,  but other types of difficulties. And if an   evidence-based intervention is not effective, so  we’re working with somebody who’s anxious or has   low mood or is struggling with their behaviour,  and we’re doing what we would normally do,   but it doesn’t seem to be working, well, maybe we  need to think about the role of their experience,   the role of their trauma, maybe we need to  reformulate weaving in some ideas from the   Cognitive Model of PTSD. And that might change  the way that we approach the intervention and,   hopefully, that means that we might be  able to offer something more effective. Thanks very much.