Approximately one third of children have experienced some form of abuse, with around one in five boys and one in four girls experiencing sexual victimisation of some form. In a US study, 60% of men and 51% of women were found to have experienced traumatic events in the forms of observing someone being seriously injured or killed or being involved in a disaster or life-threatening incident.
Just about anyone using a care service may have been a victim of trauma – and could be suffering trauma-related difficulties.
The impact of trauma on health and social care services is far-reaching and it is imperative that trauma-informed care is adopted to improve outcomes and staff wellbeing and reduce the social and economic burden associated with trauma-related difficulties.
Trauma-informed principles of care can be adopted into existing services, embedded in continuous service development or ingrained in service delivery from conception. The emphasis should be on trauma-informed ways of working becoming a part of care, not for principles to be seen as an additional task or intervention. Staff are already stretched and services are working at capacity; keeping trauma-informed principles of care simple is key to them being genuinely and routinely embedded.
Delivery of trauma-informed care does not rely upon an individual holding a formal diagnosis of post-traumatic stress disorder (PTSD) or similar syndrome, it simply means considering a person’s experiences when delivering services.
Individuals across the health and social care systems might be exhibiting a range of symptoms and associated coping mechanisms and we need to be able to identify these. Common symptoms of trauma include:
- Physical and/or emotional distress or hyperarousal.
- Poor sleep.
- Intrusive memories, dreams or nightmares.
- Acting or feeling as though the event were happening again.
- Feeling disconnected, numb or experiencing poverty of thought, speech or emotion.
- Loss of interest in relationships or activities.
- Reduction in positive emotions.
- Feeling constantly on edge, irritable or aggressive.
- Being easily startled or overly alert for danger.
- Problems concentrating.
Common coping mechanisms professionals might see are:
- Drug or alcohol use.
- Over reliance on medication such as pain killers or sleep medication.
- Social isolation.
- Avoidance of people, places or triggers.
- Keeping busy, exercising, being overly active.
- Trying to get away from situations experienced as upsetting.
Whilst these difficulties can be characteristic of a range of emotional and mental health difficulties, the most important issue to note is that they will be occurring in the context of a traumatic experience. Most often, this is the experiencing or witnessing of an event, or series of events, that involved a serious threat to personal safety, wellbeing or personal integrity and that has left the person involved feeling hopeless, helpless, shocked or injured.
It is also important to note that the severity of trauma response does not always match the severity of the incident, nor does the passage of time. There are many factors that affect the impact of an event on an individual. The prevailing principle of trauma-informed care is that if a person reports distress associated with an event, or series of events, then health and social care professionals should accept that as a lived experience and offer care that is appropriate to that experience.
The impact of trauma
We know that trauma underpins many common mental health issues, and there is a significant link between childhood adversity and incidences of mental health issues in adulthood.
We also know that trauma perpetuates trauma; those who have encountered traumatic experiences are more likely to encounter adversity and further trauma. They are also more likely to tolerate poorer care, opening the door for further vulnerability and poor health outcomes – this is especially true for older adults who have encountered childhood adversity.
As well as this, there is a growing body of evidence that trauma affects neurobiology, resulting in emotional and psychological difficulties, and those who have experienced traumatic events often experience generally poorer health outcomes; including higher need for medication and longer and more frequent hospital admissions.
Common physical disorders and symptoms associated with people who have encountered traumatic events include somatic complaints; sleep disturbances; gastrointestinal, cardiovascular, neurological, musculoskeletal, respiratory, and dermatological disorders; urological problems; and substance use disorders.
Changing the way we care
Trauma-informed care is a shift away from ‘What is wrong with you?’ towards ‘What has happened to you?’. It is a rapidly emerging area that, until relatively recently, has been limited to psychological therapies. It is widening across health and social care settings and is demonstrating improved experiences for people using services, as well as improved working environments and increased levels of satisfaction for staff. Simply, it is holistic care, bearing witness to a person’s past experiences and remaining mindful and exercising understanding of the coping mechanisms for managing distress.
It is a care delivery concept that seeks to avoid re-traumatisation. Re-traumatisation occurs when a current experience is reminiscent of past trauma, such as the inability to stop or escape a perceived or actual personal threat, or a ‘matching trigger’, such as a colour, taste or smell. The consequences could involve an individual remembering the event and associated emotional distress; vivid pictures in the mind or flashbacks that trigger an individual to act as if the event is happening again; to fight, try to escape, hide, defend oneself, help others; or even partial or full dissociation, where an individual appears not to be present in the current time as the brain enters a psychological shut-down to protect the individual from extreme distress.
Any kind of sensory, interpersonal or practical experience can activate re-traumatisation. This might include intrusive experiences, such as seclusion, restraint, personal care, forced medication, body searches and intense observation, but might also include physical examinations, being closed in a room, wound dressings being changed, tone of voice, words that might have been spoken at the time of the trauma, physical proximity or even being fed.
Re-traumatisation is common in health and social care and can affect how people engage with services and professionals. Triggers are often not recognised by those delivering care or those designing services, resulting in the potential for unnecessary distress for people receiving support, and additional demand on services. Person-centred care goes a long way towards mediating some of the issues but more is required from care delivery and development initiatives to make trauma-informed care part of a standard approach.
Adapting service delivery
The Institute for Health and Recovery, which has worked with a range of agencies in the US to develop women’s services, believes that the ideal system for developing trauma-informed care is:
- Comprehensive, accounting for a holistic range of needs akin to Maslow’s hierarchy of needs.
- Continuously caring, enabling the individual receiving care to develop relationships and access those relationships for as long as is required.
- Integrated, acknowledging interaction between mental health, trauma histories, medical conditions, substance use, disability and safety.
To achieve such a system of care delivery, liaison between agencies and involvement and collaboration of people using services is paramount. Routine screening for experiences of trauma and the impact of those experiences is helpful in developing a narrative that can inform care delivery and multi-agency working. This can be undertaken formally, using a recognised measure, or informally though conversation or activities. This narrative scaffolds the care and support that person receives, so providers can deliver flexible and responsive care that fosters people’s strengths and empowers them to live in the best way possible.
Developing an informed and compassionate workforce is key. Training, reflection and supervision underpin a healthy workforce that can understand and actively support people who may be experiencing the myriad difficulties associated with traumatic events.
Creating a physically and emotionally safe environment is also essential. Policies that encourage holistic, collaborative, respectful and person-centred care and support choice, empowerment and self-care can help to create these safe environments, as the focus is on involvement and collaboration rather than more traditional professional-led care and support. Care plans that include wellness recovery action plans, statements of advance wishes, positive behaviour support and crisis and safety planning can provide frameworks for the involvement needed for trauma-informed care to become routine practice.
In addition, small changes to the physical environment can create a calm and predictable space for people to receive care; whether in outpatient settings or inpatient or residential services. For example, improving lighting, clearly signposting exits, creating designated de-stimulation areas, thinking about the impact of noise from TVs, radios or staff duties, giving consideration to colours, décor and layout, and having individualised spaces can reduce re-traumatisation and re-activation of trauma triggers.
Support for providers to implement trauma-informed care principles is available from a range of agencies; for example, screening tools and trauma toolkits can be accessed on the Institute of Health and Recovery website and The Trauma Informed Care Project.
Individuals experiencing trauma-related difficulties are increasingly accessing health and social care systems and we must acknowledge their specific needs so that services can meet them in a co-ordinated way.
Kate Portman-Thompson is Founder of New Horizons Therapy Services. RMN, Accredited CBT Therapist (BABCP), EMDR Practitioner, Accredited CAT Practitioner (ACAT). She has worked in mental health services since 1999, focussing on psychological therapies for clients with complex needs since 2007. She has worked in both NHS and independent sectors and has delivered TF-CBT and EMDR in a leading service for trauma care in the North West. Kate recently opened an innovative psychologically-led, trauma-informed residential service for women with complex difficulties and is developing New Horizons Therapy Services; offering consultation, workshops and supervision on trauma- and gender-informed care as well as providing individual psychological therapies and psychologically-informed care. Email: email@example.com Twitter: @HorizonsTherapy
What impact do you think trauma-informed care could have on the people your service supports? How can it be implemented successfully? Share your views and any questions about this article by leaving a comment below.
The DSM-5 offers a full diagnostic list of signs and symptoms of Post-Traumatic Stress Disorder.
D’Andrea, Sharma, Zelechoski and Spinazzola, 2011, Physical Health Problems After Single Trauma Exposure: When Stress Takes Root in the Body, Journal of American Psychiatric Nurses Association, 17 (6), pp 378-92
DSM-V, 2013, Diagnostic and statistical manual of mental disorders 5th Ed, American Psychiatric Association
Substance Abuse and Mental Health Services Administration, 2014, Trauma-Informed Care in Behavioural Health Services: Treatment Improvement Protocol (TIP) Series, No. 57, Chapter 3
Sweeney, Filson, Kennedy, Collinson and Gillard, 2018, A paradigm shift: relationships in trauma-informed mental health services, BJPsych Adv. 2018;24(5):319–333