2. Type 1 trauma One off, single event Overwhelming Out of the blue

3. Type 2 trauma Repeated traumatic events Involve other people – malevolent intent Often have element of predictability / inescapability Most damaging when occur at critical periods of development

4. Examples of Type 2 trauma Physical / emotional / sexual abuse Being ignored when upset or distressed Not getting needs met and being criticised for having needs Seeing others being abused Domestic violence Torture War

5. Types of Stress Positive Stress Tolerable Stress Toxic Stress

6. Children experience persistent Stress Production of toxic amounts of Cortisol. Cortisol damages synaptic connections Connections between the cortex and limbic system may fail to develop The cortex is bypassed. Direct wiring to the limbic system. Children will react to benign situations with fight/flight reactions

7. Impact of Cortisol on Brain Development Frequent and prolonged exposure to elevated cortisol affects the development of the brain The functions diminished or lost include: Ability to learn language Understanding feelings or having words to describe them Empathy Impulse control Short-term memory.

8. Outcomes of Complex Trauma Poor cognitive development Poor sensory integration Lack of self-regulation Lack of empathy Persistent negative beliefs about self and the world Reduced capacity to make good relationships

9. The Zone of Tolerance Over activated - Too Much Overwhelmed, unsafe, angry, impulsive, racing thoughts The Zone Calm, can think clearly, can relate to others, can remember things Under activated – Too Little Numb, can’t think, disconnected, empty, “dead” (Ogden)

10. Recognising Trauma: Presentation Complex trauma generates complex reactions Difficulties with learning, memory, and regulating emotions. Flashbacks, triggers Addictions Self-medicating Self-harming Dissociation

11. Recognising Trauma: Presentation Re-victimization Problems with interpersonal and intimate relationships (including parenting), Medical and somatic concerns Forensic/Criminal issues Self-destructive and risk taking behaviours

12. Recognising Trauma: Comorbidity Alcohol misuse Substance misuse disorders Depression GAD OCD Psychosis Anger Chronic pain/health problems Neuropsychological impairments

13. Complex PTSD in ICD-11 Core symptoms of PTSD, plus persistent and pervasive impairments in each of the following: Affective functioning: Affect dysregulation, heightened emotional reactivity, violent outbursts, tendency towards dissociative states when under stress Self functioning: Persistent beliefs about oneself as diminished, defeated or worthless; pervasive feelings of shame, guilt Relational functioning: Difficulties in sustaining relationships or feeling close to others

14. Hermann, 1992: Phased Model of Working with Complex Trauma Phase 1: Safety and stabilisation Phase 2: Trauma focused work Phase 3: Reconnection and reintegration

15. Recovery In order to begin to feel safe we need to learn: That past events are no longer a danger to us Therefore we do not need to be constantly on “high alert” And, if necessary: That we can be helped to contain and process the experience in a safe, reciprocal relationship