by DAN JOHNSON · Cited by 1 — When these experiences are harmful, terrifying and overwhelming they can contribute to hostile and counterproductive beliefs about the world and others, harmful

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2SUMMARY This report focuses on how trauma-informed principles can be translated into tangible practice in residential and secure care in the UK.It suggests that the core components of trauma-informed care, as identified by Hanson and Lang (2016), can be used as a framework to organise practice and ensure services are adhering to trauma-informed principles. The report focuses on how trauma-informed principles and components have been turned into tangible practice in residential care services in the USA, Norway and Sweden and suggests practical steps practitioners can take in delivering trauma-informed services.

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3CONTENTS Summary About the authorAcknowledgements The Trip Why trauma-informed care? Aims of the Fellowship A best fit model of tangible trauma-informed care (TIC) Finding 1: No single model will do Table 1. Components of trauma-informed care services from Hanson and Lang (2016)Case Study 1. Sandhill Development Centre, New Mexico, USA Finding 2: Trauma-informed principles can create tangible practice Component 1 Œ Required sta˜ training in the impact of trauma Component 2 Œ Measure sta˜ proficiency in knowledge of impact of trauma Component 3 Œ Processes to prevent and help with sta˜ secondary trauma Component 4 Œ Sta˜ knowledge about when and how to access trauma-focused therapy Component 5 Œ Use of standardised and evidence-based assessments of trauma history and symptoms Component 6 Œ Include child™s trauma history in file and care plan Case Study 2. Jasper Mountain, Oregon, USA Component 7 Œ Availability of trained, skilled clinical providers in evidence-based, trauma-focused therapies Component 8 Œ Collaboration and information sharing within the agency related to trauma-informed services Component 9 Œ Collaboration and information sharing with other agencies related to trauma-informed service e.g. social work services 255678 8 10 11131415 16 17 18 19 2021222323

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4 Component 10 Œ Procedures to reduce risk for re-traumatisation of children Component 11 Œ Input from children and purchasers in service planning and development of a trauma-informed system Case Study 3. Magelungen, Stockholm, Sweden Component 12 Œ Provide services that are strength-based and promote positive development A. Educate children about emotions, emotional dysregulation and trauma models B. Have a range of regulation activities and make them accessible Fidgets Resistance Balance Exercise Games Sensory Soothing Massage Case Study 4. Østbytunet Treatment Centre, Near Oslo, Norway Component 13 Œ Provide a positive, safe physical environment Predictability Component 14 Œ Written policies that explicitly include and support trauma-informed principles Component 15 Œ Presence of a defined leadership position or job function specifically related to TIC ConclusionReferences 2425262727272828282930303132333435353637

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5ABOUT THE AUTHOR I™m a forensic psychologist and run a psychology service at Kibble Education and Care Centre, a specialist provider of child and youth care services, including residential and secure care. My first job in this sector was as a care worker in small units about 17 years ago and since then I™ve worked in prisons, universities and numerous residential and secure care centres across Scotland. I feel privileged to work in residential and secure care. It is not always easy but it feels like there™s always the opportunity to do something meaningful. If I had to pin down the core of my role it would be to understand what has made young people who they are and behave in the way they do. O˜en at the centre of this are the adverse and traumatic experiences they have gone through. ACKNOWLEDGEMENTS Firstly, I have to thank Claire McCartney, senior management and my team at Kibble for supporting the Fellowship even though this made their job harder. Also, all at the Churchill Trust for their support and guidance throughout all stages. Finally, to those who gave their time to host, guide and humour my incessant questions, particularly the young people.Ł Kaja Næss Johannessen and all at Ostbytunet, Norway Ł Gro Bjørnerud Rønning and team at Bakkehaugen Ungdomshjem, Oslo Ł Lisbet knudsen, Micke Rizzo, Robert Palmer and all at Magelungen, Stockholm, Sweden Ł Adrianne Walschinski and all at SaintA, Milwaukee, Wisconsin, USA Ł Dave and Joyce Ziegler and all at Jasper Mountain, Ortegon, USA Ł Kurt Wulfekuhler and all at Sandhill Centre, New Mexico, USA

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6THE TRIP1. Rush University Medical Centre, Chicago, Illinois. Team researching post-traumatic stress 2. SaintA, Milwaukee, Wisconsin. Family-centred care and educational services for children and adolescents 3. Sandhill Development Centre, Los Lunas, New Mexico. A residential programme for children ages 5 to 14 experiencing significant di˚iculties 4. Jasper Mountain, Eugene, Oregon. Services include an intensive residential treatment programme with a therapeutic school, a short-term residential centre, treatment foster care programme, community-based wraparound programme and crisis response services 5. Norwegian Centre For Violence and Traumatic Stress Studies, Oslo, Norway. Research team delivering Trauma-focused Cognitive Behavioural Therapy 6. Bakkehaugen ungdomshjem, Oslo, Norway. Residential care home for adolescents 7. Østbytunet Treatment Centre, near Oslo, Norway. A residential treatment facility for children aged 7-13. Many of the children have experienced developmental trauma 8. Magelungen, Stockholm, Sweden. Large care and education centre providing residential, outreach and day education services 1.2.3.4.6.5.7.8.

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8Secondly, all the models struggled to provide the tangible and practical advice needed by those working directly with children and young people. As a key worker said to me: The theory and concepts were great, and fit with my experience and service, but seemed to sometimes become vague and intangible when trying to use them to help young people with extremely complex, distressing and rejecting behaviour. In addition to this, every time we tried to implement a new initiative, really practical or banal obstacles got in our way: sta˚ing issues, rotas, access to resources etc. Problems that could be easily overcome once we knew what they were, but that had significantly delayed or distracted from the project. I found myself wishing that there was some way to see how other people had implemented and run trauma-informed care, to learn the lessons they had without making the same mistakes, and to focus on the practice rather than the theory and gurus. Thankfully an old memory surfaced of Kibble™s chief executive at the time describing his Churchill Fellowship, and I realised that this could be the perfect way to answer the questions I had. I know what I need to do, I just have no idea how to do it.

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9AIMS OF THE FELLOWSHIP My Fellowship therefore had two core aims: 1. To identify a model of trauma-informed care that was best fit for UK residential care: Ł to see how di˚erent models were applied to services to see which would fit best with the UK sector Ł to see how these services had overcome implementation problems and to take lessons learned 2. To focus upon where the model and theory were turned into practical and tangible practice A BEST-FIT MODEL OF TANGIBLE TRAUMA- INFORMED CARE Trauma-informed Care (TIC) has been increasingly discussed, promoted and implemented across child care services in the last decade as high rates of trauma and adversity have been recognised. There is a plethora of theories, models, articles and training providers. Many overlap but some also concentrate on di˚erent aspects of care e.g. individual treatment compared to organisational policy. The huge amount of material available can provide a challenge for practitioners in care settings looking to choose an applicable model or approach. Becker-Blease (2017), Hanson and Lang (2016) and Bath (2017) highlight a number of criticisms with TIC. It by no means should be seen as a panacea. Many of the principles overlap with other care approaches, it has been accused of displacing other useful approaches such as attachment driven practice, and has been applied in counterproductive ways (see Bath, 2017). That said, it does currently o˚er the clearest and most applicable response to the acknowledged adversity and trauma that young people in care have experienced (see Johnson, 2017). A key criticism is that there is a disproportionate focus in the literature on theory and core principles rather than the tangible practice they suggest. There is a gap about how practitioners can turn the theory and principles into daily practice and then evaluate their e˚ectiveness. The intention was to review the literature on each model that had promise, including the neurosequential model of therapeutics (Perry, 2006), sanctuary model (Bloom, 2013), and neurological reparative therapy (Ziegler, 2011). Then to visit sites that had implemented them to review their e˚ectiveness and to take practical ideas to implement in the UK. The hope was that one of the many approaches would have both the anecdotal and research evidence to suggest it would be best for residential care in the UK.

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10FINDING 1: NO SINGLE MODEL WILL DOAt the end of the Fellowship the conclusion was that no single approach fulfils all that a UK residential placement needs from it Œ no one model answers all the questions that a residential care setting asks. For example, most of the models work at di˚erent levels: some focus upon the organisational and milieu level, while others focus on individual assessments and the implications of these. While many touch on several aspects, they provide most guidance only at one particular level, and less at others, particularly when compared to an alternative approach. In turn, all contain useful guidance and strategies, there is worth in all. The best fit model appears to be a strategy whereby a residential service utilises the guidance and tools from a range of approaches, one that takes the most useful and salient of these for their own specific service. This has potential costs though: how does a service ensure that there is integrity to trauma-informed principles and that this inclusive approach does not become disorganised and inconsistent? A solution is to use an over-arching framework that can provide a core definition of trauma-informed care that can then organise the guidance from di˚erent models within it. A framework that can provide a structure to ensure that practice remains trauma-informed.

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11Hanson and Lang (2016) perhaps provide such a framework. In their critique of trauma-informed care they reviewed numerous approaches and identified those themes that were core and important to all. They concluded that there were 15 core components of trauma-informed care for children and young people. These components were organised into three levels: workforce development (WD), trauma-focused services (TFS) and organisational delivery (ORG). Abbreviated versions of each component are provided below: Table 1. Components of trauma-informed care services from Hanson and Lang (2016) LEVEL COMPONENT WD 1. Required sta˚ training in the impact of trauma WD 2. Measure sta˚ proficiency in knowledge of impact of trauma WD 3. Processes to prevent and help with sta˚ secondary trauma WD 4. Sta˚ knowledge about when and how to access trauma- focused therapy TFS 5. Use of standardised and evidence-based assessments of trauma history and symptoms TFS 6. Include child™s trauma history in file and care plan TFS 7. Availability of trained, skilled clinical providers in evidence-based, trauma-focused therapies ORG 8. Collaboration and information sharing within the agency related to trauma-informed services e.g. between care and education ORG 9. Collaboration and information sharing with other agencies related to trauma-informed service e.g. CAMHS and social work ORG 10. Procedures to reduce risk for re-traumatisation of children ORG 11. Input from children and purchasers in service planning and development of a trauma-informed system ORG 12. Provide services that are strength-based and promote positive development ORG 13. Provide a positive, safe physical environment ORG 14. Written policies that explicitly include and support trauma-informed principlesORG 15. Presence of a defined leadership position or job function specifically related to TIC

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