Geraldine Hamilton Clinical Specialist Occupational Therapist Occupational Therapy with individuals suffering from Complex Psychological Trauma. What I am going to describe today is the OT role in a service for people who have experienced psychological traumas as a result of 30 plus years of conflict in Northern Ireland, in a Trauma Resource Centre. Geraldine Hamilton Clinical Specialist Occupational Therapist

Complex PTSD Severity of complex PTSD symptoms (i.e., complex trauma symptoms) were related to: Childhood abuse and neglect Posttraumatic avoidance Feeling emotionally disconnected from other people (complex problems impact on relationships) Perceived psychological impact of troubles-related traumatic events 95% of clients have complex PTSD and this was mostly related to the trauma events but also childhood abuse, avoidance, feeling disconnected and the individual’s appraisal of what has happened to them

Trauma Events (e.g.,) Sectarian Murders Sectarian beatings/shootings Feud murders Paramilitary attacks Death threat Intimidation Displacement Witness to Suicide Kidnapping, tortures State violence Moving on then to the types of incidents experienced by those attending the Trauma Resource Centre. I should state that client’s attending are service have not only witnessed but may have also been actively involved in some of these incidents

Phase-oriented treatment Janet (1919/1925); Herman (1992); Van der Hart, Nijenhuis & Steele (2005) Establishing Safety (Stabilisation & symptom reduction) Remembrance and Mourning (memory/trauma work) Reconnection (rehabilitation & reintegration) NB: Not linear progression; like ‘a spiral’ Moving on then to our Model of treatment, it is a phase-oriented approach, This is a well established Model into which we have incorporated a Multi-disciplinary, Multi-agency Approach. The Trauma Team comprises, 3 full time Counsellors, a part-time Clinical Psychologist, a part-time Physiotherapist, a full-time Manager, who is also a Counsellor and myself, a full-time Occupational Therapist and we all play an equally important role in the client’s journey. The most major role for OT throughout, is in enabling and empowering people to develop skills and connections, to help them maximise their coping strategies and to promote an independent and fulfilling life that will sustain recovery long after treatment has ended.

Phase 1: Stabilisation Establishing Safety – Therapeutic Alliance, stabilisation; symptom reduction Education, Affirmation, Normalisation Impact of Trauma on daily routine, ADL, symptom control for anxiety/depression, building coping strategies to assist alcohol/ drug reduction, goal setting, activity planning, impact on role in family, community, advocacy re: financial situation, housing, childcare etc At this early stage of therapy the emphasis is on creating safety and a level of stability to enable clients to sustain more trauma focused processing. The OT role as you can see addresses safety in the broadest sense of the word ie starting with the individual I will look at their occupational performance in terms of getting out of bed, levels of self-care, maladaptive coping strategies such as drugs and alcohol, disabling safety behaviours, ie sitting up all night, wearing flak jacket, carrying weapons, symptom control for panic and anxiety, their routine and structure, ability to use transport, their current social supports, and then if need be referring to other agents re: housing, childcare, benefits etc

Phase 2: memory/trauma work Remembrance and Mourning/memory work maintain stabilisation, introduce physical activity facilitate expression using creative activities ongoing avoidance and safety behaviour interventions (graded exposure & motivational interviewing), commence reintegration, create new narrative At this phase the client will be telling their traumatic story with a counsellor or psychologist with the aim of transforming the memory. During this memory and trauma work the OT role is to maintain the client’s sense of safety and facilitate expression and story telling using for example, art as an activity Whilst the focus of the counsellor is to concentrate on the trauma narrative I will work alongside to find the narrative pre-trauma and facilitate the client to create their new narrative, then by breaking down tasks and working in a goal-oriented way.

Phase 3: Habilitation/Rehab/reintegration Reconnection, rehabilitation, reintegration Assessing & focusing on strengths, interests, goals; building pathways to education; vocational/educational activities; work; hobbies; fostering & maintaining good knowledge of and relationships with services in community, support networks, leisure facilities; skills development (e.g., social skills, assertiveness skills), group work This final stage of therapy at the Trauma Resource Centre is predominately OT intervention and the main focus is promoting to the client the significance of increased activity and occupations in fostering a stronger sense of self-reliance and resourcefulness. The emphasis now is on the individual’s strengths, resilience and interests and identifying skills that they feel they need or want to develop,eg assertiveness skills, learning to drive, GCSEs, then enabling and facilitating them to become actively involved in work, leisure or education by collaborating with other agencies and services available in the community.

SYMPTOM REDUCTION - FUNCTIONING Core – Functioning Having talked about the value of OT in the treatment of trauma, now it’s time to see if it’s really as good as it sounds!! This is CORE data which looked specifically at clients deemed to be in the Stabilisation phase of treatment only, the component looked at here is functioning and there is a statistically significant difference between the level of functioning of individuals at the early stage of treatment who had counselling plus OT as opposed to those who had counselling only.   SYMPTOM REDUCTION - FUNCTIONING

Client: OT Only Input Half way into the project it was being noted that in fact not all client’s require counselling to help them deal with the past and increasingly some individuals will have OT input only. This data represents the beginning and end of therapy for a young man who had OT only input. He was the victim of a sectarian assault approx 5 years ago and when I met him he had not left his house for four years except with his dad to attend appointments and relied on his mum for all activities of daily living. His main difficulty was that he had become highly avoidant and this was being compounded by the fact that his parents had become highly over protective, so I initially worked with him and his father educating them about the psychological impact of trauma and then with the client to help him attain his goal of resuming College by breaking down tasks, activity planning, goal setting and graded exposure activities. This was a lengthy process but I am pleased to say he is now back at College and on a work placement in a well known computer firm.

Focus of treatment by discipline Past Present Future This slide shows where each discipline is most effective in the treatment of trauma; counselling as you can see works with the person very much in the present making connections and reprocessing traumatic events from the past; physiotherapy is very much in the here and now and occupational therapy look’s into the person’s past levels of occupational performance, interests, skills etc in order to activity plan, develop skills and goal set in the present, to improve occupational performance to the extent that the person can move into the future with more resources to build relationships, attain vocational goals, thereby building self-esteem and self-worth that will sustain recovery long after therapy has ended. Psychological Therapy Physio-therapy Occupational Therapy