Many years ago I had friend, Sam (not her real name, but something similar). For various reasons we’d found ourselves living at a community farm hostel in Scotland. Sam had recently been released from The State Hospital and was on a high dose of haloperidol. She had facial muscle spasms from her medication and had largely lost the use of one arm in an incident of severe self-harm.
As I got to know Sam and her history, things started to make sense, but the way she’d been treated made very little sense. She had made a serious attempt on her mother’s life, because when she was very small until she was old enough to leave home, Sam’s mother had sold her to men in exchange for money to buy heroin. In the context of such extreme multiple abuse and trauma, Sam’s reactions had logic to them. I got to know Sam as a kind, generous woman who loved animals and was a protective friend. What was ‘wrong’ with Sam was what had happened to her.
When I read this paper which explores trauma informed mental health care, I thought of Sam and wondered how things could have been different for her if she’d had it. The approach determines that:
survivors in crisis are not viewed as manipulative, attention-seeking or destructive, but as trying to cope in the present moment using any available resource (p.179)
In Sam’s case this would have made perfect sense where the traditional psychiatric and criminal justice interventions seemed to make things worse for her.
The authors, who are survivor researchers, say the purpose of their paper is to ‘describe and explain trauma-informed approaches to mental health’ and to set out the case for service users, survivors and allies introducing them throughout mental health and related health and social services in the UK.
Trauma informed approaches or TIAs for mental health services are strengths-based and
they reframe complex behaviour in terms of its function in helping survival and as a response to situational or relational triggers. Reframing refers to looking at, presenting, and thinking about a phenomenon in a new and different way, and replaces traditional individual/medical model approaches to madness and distress with a social perspective (p.179)
Social models of madness and distress have been explored in an earlier blog by Alison Faulkner, and this paper adds another dimension to the blog discussion on research into the connections between trauma and psychotic symptoms.
While not an empirical research study or systematic review, this paper offers a ‘conceptual account of trauma informed approaches including consideration of why they are important, what they are and how they can become more prevalent in the UK’. It uses a narrative review methodology to provide an overview of the evidence on the effectiveness of TIAs.
Using the title word search ‘trauma and informed’, the authors searched Medline, Embase, PsycInfo, CINAHL, Cochrane Library, Sociological Abstracts, Social Policy and Practice, Global Health and Maternity and Infant Care, from the earliest date of articles in each database up until August 2014. They identified 129 unique publications that were reduced to a final 8 studies using a set of inclusion and exclusion criteria.
No RCTs were found but seven were pre-post, quasi-experimental studies, with one being a qualitative study. All studies were conducted in the USA, with four evaluations of women’s specialist services.
The paper also includes information derived from fieldwork at the only NHS Trust in the UK to be promoting trauma informed approaches in mental health.
The paper cites the key principles of trauma informed approaches as being:
- Recognition of the prevalence, signs and impacts of trauma (the ‘trauma lens’)
- Resist re-traumatisation by understanding operational practices, power differentials and other potentially re-traumatising features of psychiatric services
- Cultural, historical and gender contexts and acknowledging community or other specific trauma
- Trustworthiness and transparency with the aim of building trust
- Collaboration and mutuality with an understanding of the power imbalances between service users and staff
- Empowerment, choice and control, with the adoption of strengths based approaches
- Safety encompassing moral, physical, psychological, social and cultural safety
- Survivor partnerships and an understanding that survivor leadership, peer support and coproduction are integral to trauma informed organisations
- Pathways to trauma-specific care with support for survivors to access it where desired.
Although limited and not generalisable, the findings of the narrative overview suggest that trauma informed approaches may have beneficial effects in the following:
- Reduction in seclusion and restraint;
- Reduced post-traumatic stress symptoms and general mental health problems;
- Increased coping skills;
- Improved physical health;
- Greater treatment retention and shorter inpatient stays.
However, other outcomes did not change such as emergency room use, substance use, imprisonment and shelter use.
The additional conceptual and scoping work in the paper included an examination of the use of trauma informed approaches in the UK, with the authors exploring the potential barriers and possibilities for bringing TIAs to the UK.
Many of the barriers identified relate to the fact that ‘mental distress is understood as a scientific, medical and pharmacological problem, rather than a human, familial or social issue’ (p.183), which requires a paradigm shift. The authors highlight the need for training, organisational cultures and environments to be reformed so that staff can practice trauma informed approaches, with a recognition of how trauma could also affect them.
The authors conclude that:
There is strong and growing evidence of a link between trauma and mental health, as well as evidence that the current mental health system can re-traumatise trauma survivors. There is also emerging evidence that trauma-informed systems are effective and can benefit staff and trauma survivors.
The authors conclude that, if we are to see an effective introduction of trauma informed approaches into the UK, we need:
survivor leaders and champions advocating for values-based system change with passion and commitment.
Strengths and limitations
The authors fully acknowledge the highly limited nature of the evidence base on effectiveness, which they report as one of their findings. However, they offer a comprehensive account of what trauma informed approaches are, and assess their implementation for mental health services in the UK, making the crucial point that this should be led by survivor champions and leaders.
This paper sets out a comprehensive case for furthering trauma informed approaches in mental health and allied services in the UK. It also highlights the need to invest in and undertake further research into the safety and effectiveness of these approaches, as well as stressing the importance of survivor leadership in any TIA programme.
In the light of increasing concern about patient safety on psychiatric wards, and testimonies of experiences of psychiatric care that are re-traumatising, this paper provides an urgent new blueprint for mental health care paradigm change. This urgency is surely demonstrated by a recent Tweet sent by survivor activist Alison Cameron from a private psychiatric hospital on an NHS contract. She reported that people in intensive care were being kept in a cage when outside. It could be Sam in that cage.
Sweeney A, Clement S, Filson B, Kennedy A. (2016) Trauma-informed mental healthcare in the UK: what is it and how can we further its development? Mental Health Review Journal 21 (3) 174-192.