Our Trauma Informed Psychological Service
How Clinical Psychologists Work
The profession of clinical psychology is designed to provide clinical services at the level of the individual, the team, and wider organisational system.
They are taught to make sense of problems by adopting what is called a Bio-Psycho-Social perspective. In young people's services they consider whether difficulties are being maintained by the body, the mind, the system around the child, or complex interactions between all three. This method of making sense of problems in context is called ‘formulating’. This allows their clinical work to address the actual source of the problem which increases the chances of meaningful change.
Adopting a Bio-Psycho-Social perspective allows psychologists to consider, specifically why a behaviour is occurring rather than simply attempting to treat the surface symptoms. This means that the impact of their interventions can reach beyond the child to address the elements of their world that are likely to have the most positive impact. In the case of young people with trauma and attachment difficulties the most crucial element is likely to be the nature of their relationships.
“Team formulation is in keeping with the profession’s wider remit to work at team, service and organisational level. The clinical psychology leadership framework lists one of the roles of a qualified psychologist as; Lead on psychological formulation within your team. This might include supervising and training other members of the multidisciplinary team.” (British Psychological Society 2011)
“We saw evidence of secure and meaningful relationships that had developed over time. These were based upon empathy, compassion, love and fun. We observed the young people having fun with the staff and they told us they would turn to managers and staff when they needed extra support.” (Care Inspection Report Dec 2019)
Key Features of Our Service
Trauma and attachment focused service provision
While we can observe the external behavioural results of trauma, abuse and neglect, addressing these issues requires that the emotional world of the child is influenced through the quality of their relationships becoming the focus for intervention. The issues arose due to relationship disruption, recovery happens only in the context of relationship repair.
Expert clinicians now agree that our understanding of relationship based trauma should be based on a dynamic, responsive but non linear stage-oriented approach, because individuals require an initial and often lengthy period to develop the emotional stability that forms the foundation for all future progress, (Herman 1992). Establishing an interconnected sense of emotional safety and the ability to regulate emotion through relationships are the necessary prerequisites to developing a coherent sense of self and then being able to engage more fully with life.
In accordance with the UK Psychological Trauma Society guideline on complex (developmental) trauma, all psychological assessment, formulation and systemic orientated treatment work within this service is grounded within best practice evidence in relation to a three phase treatment approach to attachment based trauma.
“The nurturing approach used in the interactions from staff towards young people had been key in helping the young people recovering from earlier trauma, make sense of their past and develop feelings of safety, confidence and self -belief. We found that young people were making good progress academically and for some this was significant given previous non engagement in education.” (Care Inspection Report Nov 2018)
“I have a better understanding of how trauma affects the brain and why certain behaviours are being displayed. I feel I am now better able to help and nurture our young people.” (Attachment & Trauma training feedback 2018)
Mandatory trauma and attachment training for all staff
Our staff training programme is unique as its design is explicitly orientated around the Bio-Psycho-Social approach, and the main emphasis is on implementation of ideas in daily practice. This provides staff with the building blocks to begin to 'think like a psychologist' in their everyday interactions with young people. It allows staff to tailor trauma informed care and education plans to the specific needs of the child, and to prioritise their attachment needs as the foundation for progress. Attendees are orientated towards reflection on how their therapeutic relationship with the young person can be optimised as one of the primary agents of change.
Key outcomes of our training programme include staff knowledge, competence and confidence significantly increasing, which results in improved containment of trauma symptoms and reduced reenactment of unhelpful dynamics. As a result, stability is achieved more rapidly as young people access a higher level of psychologically informed care compared to more traditional service delivery models.
The core concepts and design features of our trauma and attachment training won a number of best practice and service innovation awards in the independent healthcare sector in 2014 and 2016 and results from our current programme are currently being prepared for publication.
“Through discussions with staff and our observations we saw that care and support of young people was linked to research and good practice; with good understanding of theoretical issues relating to trauma, attachment and cognitive development for example.” (Care Inspection Report Sept 2019)
“The training has taught me how to be more reflective about how young people, staff and myself are feeling. I feel I can be more confident in assertively providing a scientifically based rationale for my practice.” (Attachment & Trauma training feedback 2018)
Systemic working in a consultancy model
Just as one would not attempt to offer psychological intervention to an unhappy couple by only seeing one half of the partnership, we do not expect a young person's functioning to improve by only working with them in isolation. Specifically, the young person's world becomes the client, not simply the individual. Delivering a service this way has a name, it is called a 'systemic working'. Difficulties are viewed as being embedded in context and change occurs by addressing the dynamics of the whole picture. This widens the scope and range of effective psychological approaches, allowing improved understanding of the case and the potential for greater impact as a result.
“Professional policy guidelines call for effective use of clinical psychology through indirect ways of working, to increase clients’ access to psychological therapies.” (British Psychological Society, 2011)
“The input from the Psychologist in working with young people and in providing consultations, training and guidance to staff was a particular strength. Staff members had a good level of understanding of the impact of trauma and were able to shape their interventions with young people in an informed way.” (Care Inspection Report Nov 2018)
"When a crisis situation occurs, I will have better knowledge and understanding of what is happening and the best way to support the young person.” (Attachment & Trauma training feedback 2020)
Creative, innovative and child centred
Children and young people often have different ways of expressing themselves when in distress, therefore psychologists work in a different way with those of young ages than with adults. Typical talking therapies may not be right for those who struggle to open up about their feelings. Young people with attachment related trauma difficulties require careful ways of psychological working due to their developmental stage, emotional fragility and difficulties with trust (Van Der Kolk 2009). Development of self and processing of difficult experiences in young people usually occurs through movement, play and creative activities.
Repeating patterns of progress and destabilisation are one of the defining features of trauma presentations. Stage orientated trauma recovery approaches guide us in terms of client readiness to engage with and benefit from direct work. This helps to ensure appropriate timing and pacing of different interventions.
“During our inspection, we considered the therapeutic practice of staff and found that the stability of the service had created space for work to be undertaken with young people. This is credibly supported by the psychologist attached to the organisation.” (Care Inspection Report Dec 2019)
“I will give more thought to the emotions of the child rather than the displayed behaviours.” (Attachment & Trauma training feedback 2019)
Our young people have complex needs some of which may be long standing. Our psychology service is committed to ensuring that, when required, young people have access to NHS based emergency care, psychiatric prescribing, diagnostic services, specialist intervention and forensic assessment. It is essential that when moving on from our services there is a seamless transition to adult services and this is supported by the psychological treatment history being firmly embedded in their NHS case narrative.
Formulation based communication
We are mindful that as part of a sense making process at some point in the future as adults, our clients may wish to access their notes. Our formal correspondence with referrers, families, and other professionals will always aim to be clear, succinct and jargon free. This ensures that everyone has access to the psychological formulation that helps them make sense of the complex and often challenging presentations that we work with. This increases insight regarding which factors are maintaining progress, facilitates improved coordination between services and allows better future planning.
British Psychological Society, 2011. Guidelines for Clinical Psychology Services;
British Psychological Society, 2011. Good Practice Guidelines on the use of Psychological Formulation
NES, 2019. The Scottish Psychological Trauma Training Plan
UK Psychological Trauma Society guideline on complex trauma, 2017