For the uninitiated TIAs and ACEs might sound like poker slang or the latest UK Grime artists, but they are acronyms for Trauma-Informed Approaches (TIAs) and Adverse Childhood Experiences (ACEs). Many hope that these two interlinked developments in understanding and responding to people experiencing ongoing mental distress aren’t just another example of new panaceas that cyclically occur in mental health policy and practice, but disappear down the great NHS jargon plughole and revert to treatment as usual.
The authors of an important editorial in the Journal of Mental Health are among their number, and suggest that if service users and survivors retain power and influence over what trauma-informed approaches are and should be, then there could be the possibility of a revolution in the way we understand and treat mental distress. From their perspective as trauma survivors and mental health academics, Sweeney and Taggart take a serious look at the potential and risks for trauma-informed approaches as they are introduced into mainstream mental health systems and services, forewarning and forearming us against the possibility of such approaches being misunderstood and misapplied.
Trauma-informed approaches in mental health were influenced by research into adverse childhood experiences, where an individual has been through trauma as a child, such as exposure to violence or abuse, that damages their mental and physical health in later life. This link was first established by a US public health clinical researcher named Vincent Felitti who led the Adverse Childhood Experiences Study in 1998. In this clip you can hear him speak about his work, and the origins of his investigations (this includes references to childhood sexual abuse). Since then more research into the effects of adverse childhood experiences suggest that they are a major risk factor for many health conditions, something that is a serious public health concern (Hughes et al, 2017).
Studies of the effects of adverse childhood experiences on mental health have been blogged about for the Mental Elf, here and here and earlier work by Sweeney and colleagues on trauma-informed approaches appeared in a blog here. Psychologist and mental health campaigner Dr Jay Watts has argued that mental health services can end up re-traumatising people who have experienced abuse and violence and that mental health practitioners should adopt a ‘trauma lens’. Her position is reflected further in Sweeney and Taggart’s paper which aims to explain how and why:
trauma-informed approaches have the potential to lead to a fundamental shift in how mental health services are organised and delivered, meaning that they are better able to meet the needs of service users.
The authors use research evidence and foundational theories to underpin their assessment of the field. They provide an overview of the literature on trauma-informed approaches, scoping out the influences and drivers, and presenting the key points for understanding and the main misunderstandings.
According to Sweeney and Taggart there are two major drivers for trauma-informed approaches in mental health:
- Adverse childhood experiences and their effects on health and mental health in later life.
- Iatrogenic harm in psychiatry and mental health services, typified by coercion and control and practices like restraint and seclusion that ‘recreate abuse through “power over” relationships’, which can re-traumatise and prevent recovery.
Again, drawing on the literature, the authors then go on to sketch out how trauma-informed approaches should be understood and implemented ‘as an organisational change process, focused on preventing (re)traumatisation within services’:
- ‘Seeing through a trauma lens.
- Adopting a broad definition of trauma extending beyond PTSD.
- Making trauma enquiries sensitively.
- Referring people to evidence-based, trauma specific support.
- Addressing vicarious trauma and retraumatisation.
- Prioritising trustworthiness and transparency.
- Moving towards collaborative relationships.
- Adopting strengths-based approaches.
- Prioritising emotional and physical safety.
- Working in partnership with trauma survivors.’
Most importantly, perhaps, the authors are then very clear about some of the common misconceptions that they perceive to be risk factors for achieving the fundamental shift in mental health organisation and delivery required, highlighting the need to ‘proceed with caution’:
- ‘Trauma-informed approaches claim that all mental health service users have experienced trauma;
- Trauma-informed approaches treat people who have experienced trauma;
- The shift from asking what’s wrong with you, to considering what’s happened to you, is a literal one;
- Trauma-informed approaches are purely conceptual;
- Trauma-informed approaches are implemented by individual practitioners;
- This happens already.’
The authors warn that
there is an inevitable risk of co-option: that trauma-informed approaches will come to mean little more than treatment as usual repackaged as trauma-informed’
and emphasise ‘the need for a realignment of the knowledge base, power and responsibility.’
Among other things, the authors conclude that:
“Trauma” is a category [that] has political and social implications as well as psychiatric ones, and mental health services not only need to change their practices, but to engage with communities where trauma occurs and groups identifying as trauma survivors.
Given the centrality of trust and empowerment to healing for trauma survivors, it is vital that grassroots survivor organisations shape the research and development agenda in this area.
Strengths and limitations
Given that this is an editorial paper, it’s difficult to assess the strengths and limitations as you would with a conventional research study. However, a major strength is that the piece is written by two academics (one of whom is a practitioner) who are both trauma survivors. This experiential knowledge gives them grounded insight into the topic and the importance of getting trauma-informed approaches right.
The paper could have benefited from a slightly more extended literature overview, particularly for the drivers and understandings, which perhaps needed a firmer evidence base to strengthen the argument. Greater definition and exploration of the issues relating to ‘communities where trauma occurs’ would have been welcome.
In sum, Sweeney and Taggart offer a valuable early warning of what could impede and support trauma-informed approaches reforming mental health services, emphasising that service users and survivors must take a leading role if practice is to change. They remind us that it is important to be cautious, given the clinical manualisation of user-originated radical approaches such as recovery and misunderstandings about the implications and value of peer support in mainstream NHS mental health services.
Sweeney A, Taggart D. (2018) (Mis)understanding trauma-informed approaches in mental health. Journal of Mental Health DOI: 10.1080/09638237.2018.1520973 [Full Text]
Hughes, K., Bellis, M.A., Hardcastle, K.A. et al. (2017) The effect of multiple adverse childhood experiences on health: a systematic review and meta-analysis The Lancet Public Health 2 (8) pp.356-366 [Full Text]
- Photo by JR Korpa on Unsplash
- Photo by Carlos Arthur M.R on Unsplash
- Sergej Xarkonnen CC BY 2.0
Thank you for this piece which challenge all of us:
1. Don’t ignore invisible #trauma.
2. Don’t reduce the trauma model to another disease model.
It is encouraging to see related challenges to the traditional bio-medical approach such as the Power Threat Meaning Famework (Johnstone et al., 2018) and Jim van Os & colleagues’ call for radical mental health service change (World Psychiatry, 2019, 18: 88-96. doi:10.1002/wps.20609).