“Weary” – the wordlessness of trauma by Iona – used with kind permission
“People within marginalised groups deserve the same value, support, respect & opportunities as any other citizen. The fact they may have experienced multiple ACES tells us they require an increased level of support. I pray ACES awareness eradicates the level of stigma & attitudes.” Mark
On the 3rd of November, I tweeted the following call for contributions to people on Twitter:
Jane Mulcahy @janehmul Folks interested in raising awareness of #ACEs and childhood trauma, what 3-5 questions should be discussed at the first cross sectoral public meeting on the subject in Dublin on November 28th? Even if you can’t make it along, you can have a voice by responding to this tweet!!! 5:52 AM – 3 Nov 2018
People from Ireland and further afield (e.g. Scotland, Wales, England, America, Belgium, Macedonia, etc) enthusiastically contributed questions and comments to help inform the discussion on November 28th. In fact, the flurry of Twitter responses proved very helpful to me in terms of deciding the composition of the expert panel.
Obviously, since the entire Towards an ACE-Aware, trauma-responsive Ireland discussion, including Q&A, will be less than two hours long, it is impossible to delve into any of these complex issues in the kind of depth they deserve. Every single topic that will be touched on at the meeting on the 28th merits days of animated discussion in its own right.
Indeed, there are subjects including the impact of cultural trauma and ethnic discrimination on the Travelling Community, and matters relating to ACEs, trauma and retraumatising experiences in the context of asylum-seekers, the Direct Provision system and racism as a source of profound “toxic stress” (see the trailer for James Redford’s acclaimed movie on ACEs, Resilience at https://vimeo.com/137282528) that will not be discussed by the panel, but absolutely deserve special focus, and will, hopefully, be raised by members of the audience. (Several unsuccessful attempts were, however, made to source panel contributors on these topics)
The goal of the discussion is to give the audience a sense of the interconnectedness of seemingly disconnected issues and whet their appetite for future discussions and cross sector engagement.
Contributors, including people who are trauma survivors, will give a brief overview of the importance of healthy parent/infant attachment, parenting with ACEs, addressing trauma in the classroom, ACEs and healthcare, addiction and homelessness, offending behaviour and imprisonment, the intergenerational impact of historical abuse, the challenges of implementing trauma-informed training in practice, the need for stabilization and safety in the therapy context and, crucially, the adverse experience of class.
As organiser of the discussion, my hope is to energize the gathering to be like the Brooklyn girls in Tom Waits’ classic song Downtown Train (https://youtu.be/rLtZKkCIVmI) who “try so hard to break out of their little worlds” – (the often lonely, defensive, professional silo?) – and take collective, collaborative, ACE-aware, trauma-responsive action for better individual and societal outcomes.
If we accept the interconnectedness of the various issues raised, then we must accept that we are stronger and more effective working together and learning from one another. If we want a heart-centred, kind, compassionate, non-judgmental, whole systems approach to preventing ACEs in the first instance and a trauma-responsive approach across public services to deal holistically with the needs of “unrecovered trauma survivors” (Whitfield, 1998), then we can make it happen.
If we become more self-aware, open and curious, alter our personal practice in small, subtle ways, interact differently in our day to day work to vulnerable clients, attuning with greater patience and kindness, watching our “mirror neurons”, engaging in warm, pro-social “serve and return” exchanges, and become more proactively political, we can work wonders.
We should not be afraid of, or embarrassed about being political. Professor Sir Al Aynsley-Green gave an impassioned keynote address at the ACEs conference in Nottingham Trent as Visiting Professor for Child Advocacy Last Wednesday, where he said “sod calm – get angry”. I tweeted the following:
“Prof Sir Al plugs his new book on betrayal of children in Britain. He’s one of the few people who “can tell it as it is”, he doesn’t need another pension, nor a “reference from Mrs May”. @teresamayMP & her colleagues have decimated childhood thru #austerity & #Brexit obsession”
In response to a comment from guru Suzanne Zeedyk, who observed that David Cameron’s political stance at the #ACEAwareNation conference in Glasgow was deemed to be inappropriate by some audience members, I tweeted back:
“It is impossible to be too #political about the impact of childhood #trauma & the intersection w poverty & social marginalization. We have unequal, inequitable conditions at birth. We can and shd do more to help all children #thrive. #ACEs are as political as it gets”
I really mean this. ACEs are as political as it gets. Complex trauma (diagnostically known as Complex PTSD since the publication of the WHO’s ICD-11 in June 2018 – see https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5774423/) does not discriminate on the basis of colour, race, religion or educational attainment, in the sense that domestic violence, child sex abuse, physical and emotional abuse and emotional neglect happen in homes all across the world (see my article “Hurting Children” at p, 98 of Curing Violence – http://justiceinnovation.org/wp-content/uploads/2018/10/Curing-Violence-reduced-size.pdf). That being said, as trauma specialist Bessel Van der Kolk writes in his book “The Body Keeps the Score” exposure to trauma is stubbornly enmeshed with class and deprivation:
“I wish I could separate trauma from politics, but as long as we continue to live in denial and treat only trauma while ignoring its origins, we are bound to fail. In today’s world your ZIP code, even more than your genetic code, determines whether you will lead a safe and healthy life. People’s income, family structure, housing, employment, and educational opportunities affect not only their risk of developing traumatic stress but also their access to effective help to address it. … Trauma breeds further trauma; hurt people hurt other people.” (p. 350)
I have argued elsewhere in relation to offending behaviour that criminality and the consequent loss of liberty may, for many prisoners, be a minor aspect of their personal adversity stories. Offenders tend to come from communities where ACEs are all around them; in their homes, on their streets, in their schools, doctor’s surgeries and emergency rooms.(https://www.researchgate.net/publication/324531733_Daring_to_Ask_What_Happened_to_You_-_Why_Correctional_Systems_Must_Become_Trauma-Responsive)
In “The Healing Well”, Dr Nadine Burke Harris states that while toxic stress is about basic human biology, in communities that are extremely deprived, where there are low levels of resources at the individual and collective level, trauma is “endemic”, meaning that “it isn’t just handed down from parent to child and encoded in the epigenome; it is passed from person to person, becoming embedded in the DNA of society” (pp. 132-3).
There is strength in numbers. If we harness the personal narratives of survival, the emphasis on relational health and wealth which build resilience (see https://youtu.be/16alOVWWo1s and https://weneedtotalkaboutchildrensmentalhealth.wordpress.com/2018/01/14/have-you-ever-seen-inside-a-golf-ball-and-what-makes-it-so-resilient/) and the diverse knowledge and skill sets of professionals from attachment specialists, Early Years practitioners, primary school teachers, social workers, GPs, addiction counselors, homeless service personnel, lawyers, prison officers, and beyond, we can make immense positive differences in the lives of others.
Ideally, we should make individual and joint submissions to politicians and policy-makers calling for massive, sustained investment in supports fostering healthy attachment and high quality Early Years services, especially expansion of ABC-type programmes in deprived communities, coupled with huge State-funded investment in training in trauma-informed practice at all levels of core services. We should not be so preoccupied with our own small, though crucial part of the puzzle, that we lose sight of the big picture and remain disconnected from natural allies. Nor should be so obsessed with acquiring and maintaining scare funding that the people whom that funding is meant to assist are not our dominant focus. We need to resist the urge to change what we say we do on paper, just to fit the new funding criteria, as well as to over-promise and under-deliver. As my Twitter pal Sally Croachy from the Highlands in Scotland says we need to continuously ask “whose needs are being met and why?”
Trauma-informed does not mean learning about trauma and then continuing to do the same old, same old pointless, damaging, disrespectful thing as before. People like systems are slow to change. However, since trauma is essentially rupture at a relational level, it is at the relational level that healing has to occur. Each of us, regardless of what we might do for a living, has a role to play. We can choose to be kinder, more nurturing and patient. We can take it upon ourselves to care more about what happens to other people’s children.
Below are a selection of the questions and comments submitted to my Tweet. Thanks to everyone who took the time to engage with the conversation that, frankly, to a greater or lesser degree relevant to us all.
In no particular order thanks to Cissy, Iona, James, Thomas, Shane, Angela, Benjamin, Cliona, Jane, Margaret, Fierce Social Worker, Katherine, Kathryn, Marie, Martin, Mark, Jonathan, Warren, Linda, Alison, Robin, Sue, Dave, Sarah, Nicola, Aidan, Jean, Sally, Steve, Nigel, Rhiannon, Rebecca, ACEs Connection, ACE Aware Nation, Iain (Smithy), Suzanne, Shelagh, Pam, Alan, East Ayrshire Psychology Service, Be Well Do Well, Gary and Sue.
Early Years Strategy (#First 5) & other policy initiatives
“How will the soon to be published Early Years Strategy inform this debate?” (See First 5: A Whole-of-Government Strategy for Babies, Young Children and their Families 2019-2028, launched on the eve of World Children’s Day, available at https://www.dcya.gov.ie/documents/earlyyears/19112018_4966_DCYA_EarlyYears_Booklet_A4_v22_WEB.pdf – see also https://www.youtube.com/watch?v=JKKvkAikvOs)
“Are CYPSCs or PPFS a possible vehicle for developing a movement / disseminating info / securing investment / rolling out ACE Aware & Trauma informed training / influencing policy?”
(*CYPSCs are Children and Young People’s Services Committees: see https://www.cypsc.ie PPFS is Tusla’s Prevention Partnership and Family Support approach: see https://www.tusla.ie/services/family-community-support/prevention-partnership-and-family-support-programme/)
Voices of Children
@MargaretTuite1 Nov 3 “Trauma almost invariably involves not being seen, not being mirrored and not being taken into account. Treatment needs to reactivate the capacity…” (The body keeps the score). Q on how to ensure that children’s participation rights are part of all discussion/action on ACEs”
What is evidence-based best practice in addressing ACEs?
“How can the #aces movement ensure its support of actions/responses are those that are based in best practice /solid evidence?”
Prevention through attention to social structures:
“Can #ACEs movement better contextulise the lived experience within wider stuctural environments so not add stigma or shame parents/practitioners/communities? Can awareness be harnessed to shift policy, training/education and institutional practices?#reflectivepractice #PEI #imh”
There is a link between Trauma and Austerity. What is the role of Human Rights and supporting vulnerable families?
“Children & families are being traumatized by inadequate healthcare, housing & welfare protections which contribute to high ACEs. Focus needs to be on prevention by improving living conditions & social supports”
“Please ask them not to restrict their focus to the aces list. Poverty matters. Community violence. Race hate. Etc. Adversity isn’t constrained to families.”
(See the whole thread in response to this tweet from the Nottingtham Trent conference on ACEs
It’s not abt a “right to ask”. It’s abt a “right to be asked”. We leave kids to suffer in silence the world over & the result is destructive
#relationships, addiction, mental health problems, self-harming, offending behaviour. Ask any unrecovered trauma survivor in prison # ACEs
… I don’t think ACEs is a ‘grand theory’, universally relevant to all ppl regardless of context. This is one of the things I find troubling about ACEs claims. It’s not a magical silver bullet, and people who ask questions about it are not denying the impact of abuse or neglect
Yes I understand that but it can’t be treated as predictive or used as a screening tool. It is absolutely necessary that people who have had awful ecperiences have this recognised but also that they are not biologically broken
Breaking through personal and societal denial
“1. Understanding denial and its purpose? 2. Why is denial a fantastic coping mechanism? 3.The role of “toxic shame” in personal and interpersonal relationships? 4. What is the dynamic of cognitive dissonance in understanding and addressing ACEs?”
“Why there has been so much resistance to accepting that what happens in our childhoods impacts both our physical and mental health into adulthood?”
“What systems, structures and models maintain the status quo?”
“What changes can be made by thinking big AND starting small?”
Dr Warren Larkin @warren_larkin Nov 4 “What are the main barriers that prevent professionals asking help seeking clients about their adverse life experiences? What key actions would enable system change here? Which leaders do we need on board and in what order to enable the above? Great initiative Jane!”
“How do we meaningfully explore, address or attempt to heal our national history of trauma and ACES (think Tuam babies, Magdalenes)?”
Maternity, attachment & parental supports
“From my clinic, I see pregnancy + parenthood as significant triggers in ACE adults and adult children of ACE parents. Query specific interventions/ supports to obviate PND in either mother/father?”
“How do we support expectant parents to be mindful of infant mental health? How can this be woven into prenatal care? How can we support perinatal mental health, how can we build an emotional literacy around attachment in early years education?”
“Do parents have easy access to relationship based services to help them, especially if they are troubled by aftermath of own childhood trauma, protect their children from chronic stress?”
Trauma and health outcomes:
“One of the most important hypotheses prompted by the ACE research is that the prevention of childhood adversities may have substantial population level health benefits.”
“Sadly drug related deaths are increasing, along with alcohol deaths & suicide numbers make tragic reading; people with ACES are likely being of high prevalence through multiple factors. These can be prevented through a compassionate approach where everyone is valued & needs met”.
“How does knowledge/understanding of childhood trauma change practice? How could this change access to CAMHS? How does this impact on concepts of mental illness and the diagnosis of behaviour disorders in childhood?”
“If mental health services actually focused on mental health rather than mental illness would they have a wider impact? (A bit tongue in cheek). Consultation can be better and more preventive than therapy”.
“Why are MH services still treating only the symptoms of adult survivors with unresolved ACEs? Why don’t they look at the cause & treat the trauma? When will they catch up?”
“What percentage of clients accessing mental health services are due to organic mental health issues as opposed to the sequelea of adversity?”
@ClionaNi: “If you look at people who are homeless or other marginalised groups, the amount of trauma they have suffered in their lives is huge. A lot of them, probably up to 3/4, have had severe sexual or physical abuse in childhood and in a way, more damaging is the neglect.
They haven’t had a parental figure to help them feel safe and loved and regulate their emotions. I would see that that is the route of all the behaviours and difficulties in addiction, difficulties interacting w other people & difficulties in interacting w health services”. #ACEs
The “primal human need is to feel loved and accepted and until you have that you are not going to be able to address taking your hepatitis C treatment or whatever it is. So we really try to provide a service that within professional boundaries, provides that personal warmth.”
“Stop treating illness and start teaching health.”
“Salutogenesis is another way of thinking about resilience to trauma. If we have enough we can survive a lot more traumatic experiences than if we are deprived of it’s core components, especially social security” (see my interview on trauma-informed medicine with J Tomlinson https://soundcloud.com/jane-mulcahy/dr-jonathan-tomlinson-law-and-justice-interview …)
See this clip of Ironweed, adapted from the Pulitzer prize winning book by William Kennedy with Tom Waits as Rudy telling Jack Nicholson about his cancer diagnosis – https://www.youtube.com/watch?v=5_9eCULwZ3o
Supporting and valuing Early Years services
“Our early childhood carers are underpaid and often undervalued…how do we support this already over burdened and undervalued sector to have a role in buffering and building resilience?”
Trauma in the classroom
“School is massive”
“Do teacher training colleges educate future teachers about ACEs and the impact on children’s ability to regulate and learn?”
“Do your schools have professional development opportunities in place, allowing staff to recognise the impact ACE’s have on the young people whom they support? Training of this nature should be a fundamental aspect of the recruitment/induction process.”
“I would be interested in how services can support the network around the child, in addition to the child, to ensure the best possible long-term outcomes.”
“How can we plug the significant gap in robust research into what works to support attainment, wellbeing and other educational outcomes for young people with ACEs?”
Concerns about the ACE Score & wider evidence
“Are ACEs the new moralizing standards in Child Protection – retraumatising mothers and children?”
How do we counter concerns about how checklist is put together?
What does the ACE Score actually mean?
What are the assumptions implicit in what items were included in the original ACEs study?
What assumptions might effect how the scores are interpreted?
“There is a temptation to pursue this hypothesis with more studies about which items best predict health problems. But the most useful confirmation of this hypothesis is not through the refinement of better ACE screening tools: Rather it is through the development and evaluation of programs that prevent the occurrence of childhood adversities in the first place and then the experimental demonstration of the population health effects from their dissemination.”
“One thing I’d caution is in leaping to absolute conclusions based on the ever-growing evidence. The relationship between genes, experiences and behaviours is not yet fully understood and seems to be amazingly complex and lifelong. But we work with the indications.
Children in the Care system
“How do we translate the knowledge of developmental trauma into tangible improvements for children in care?”
“How (knowing the traumatic pathways into state care) how & why we don’t proactively strive to improve the mental wellbeing of young people in care, as apposed to a reactive response when it’s often too little too late & exploiting their resilience too!!”
From child victim to adult victim (and all too-often perpetrator)
What do we do about children growing up in homes with parental alcohol misuse, who are not on any social care radar, and who are not visible to any healthcare professional as the parent causing the trauma for the child is not in treatment?
“One point: we can get fixated about ACEs because the evidence is so strong. But ACE’s is neuroplasticity of children; and Adverse ADULT Experiences (AAEs) must be included in your deliberations as the two interact.”
“Is it possible that ‘some’ of the adverse adult experience could be a result of the adult growing up as a child with ACES? Just asking as this is my experience. The child with high ACE is perhaps less equipped. 100% agree that children AND adults need support.”
“Trauma and Gender – pathologising victims of abuse in mental health services?”
“95% addiction involves ACES 4 or more #nadineburke #gabormate. Addiction aside, children with high ACES grow into adults with reduced problem solving skills & lower self esteem which can therefore keep them stuck in patterns they might otherwise have escaped.”
James Docherty @Prev_Justice Nov 4 “I was told by a children and family’s social worker that not all addictions are caused by ACEs, that some addicts are just selfish pricks and addiction is an exaggeration!! I just replied all drug addicts present as selfish as that’s how it expresses itself to the untrained eye!”
Healing from ACEs
“I would be interested in how services can support the network around the child, in addition to the child, to ensure the best possible long-term outcomes.”
“What strategies are appropriate and effective for interacting with unrecovered trauma survivors?”
#TraumaEmpowered – “Nothing about me without me!”
Jane Mulcahy @janehmul Nov 25 #TraumaEmpowered = The people most impacted by any given social problem are the Experts!” says @drjimwalters. Who agrees with him? I do, Academics? Psychiatrists? Psychologists? Human rights advocates? Addiction counselors? Social Workers? Homeless services staff? Do you agree?
“I do. “Those closest to the pain should be closest to the power.”
“Love this. However, it takes practitioners to see past the current crisis that brought these experts through the door and see what is underneath waiting to be unlocked through love and support. We must set the table properly for people to become their best selves!”
“And show up as guests in the heart not with disciplinary or instructional mindsets and say what can we learn together and from one another? That shift @SporLin speaks so brilliantly about.”
“How are we (meeting) going to respect + value + use to best effect the range of professional + personal experience + expertise in the room?”
Desirability of a more nurturing approach
“Wherever I look I see signs of the commandments to honour ones Parents and nowhere of a commandment that calls for the respect of a child” Alice Miller
“Shaming and humiliating children causes self loathing they feel unloved and unworthy we must nurture and love all of our children first and foremost
James Docherty @Prev_Justice Nov 3 “Absolutely, but it’s just not just the children carrying that stuff around inside them. I think that’s why ACEs kicks up many misunderstandings and disturbance as it’s pushes peoples emotional hotspots. So the key for me is to try and love and nurture everybody.”
“[A]bsolutely right, empathy not sympathy, with lots of love and nurturing is what’s need alongside timely therapeutic support.”
Need for comprehensive trauma training and a more collaborative, relationships-based, joined-up approach
How can all social and public services need to become trauma-informed as a matter of urgency?
“How do we shift thinking and practice in services designed to respond to presenting need to one that responds to root cause?”
“How does knowledge/understanding childhood trauma change practice? How would this reduce school exclusions? How does this change residential child care, foster care and post adoption support? How should this change maternity services?”
“How can CAMHS, education, social services and 3rd sector agencies work together to foster resilience-building relationships with traumatised youth?”
“It’s a ‘heart thing’ – difficult to express. RE-sensitize. Inform. Then educate and support. It also depends on the level of brainwashing-Ireland is at the most intense. We are past shaming, judging or lambasting. And too much ‘craic’ and false creativity to distract us from reality.”
East Ayrshire Psychological Services @eac_psychology Nov 3 How do we meet the scale of emotional containment that’s required across all services to ensure all practitioners are able to be regulated, kind, non-triggering & their best selves? We need this as well as increase knowledge & skill to make a big difference to people.