TraumaInformedApproaches

TraumaInformedCare:ImplicationsforPractice

D2N2TeachingPartnership,November,2018

stephen.regel@nottingham.ac.ukstephen.regel@nottshc.nhs.uk

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•  Definingtrauma….?

•  WhatisaTraumaInformedApproach(TIAs)

•  Barriers?•  Complextrauma?

•  Contexts?•  Staffcareandwellbeing–whocares?•  Posttraumaticgrowth

•  ThefutureofTIAandimplicationsforpractice..?

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“Whileslicingrashersofbacon,yourgrocerseversthearteryinhiswrist”

“Returningfromtheclubroomafteryourmeeting,withthreeofyourPatrol,youhearawomanscreaming‘Fire!’fromanupperwindowofalonelycottageonthemoors.Runningtothespot,youseesmokepouringfromthewindow.Thewoman,holdingababyinherarms,hasobviouslylostherhead;twobiggerchildrenarehangingoverthewindowledgecrying.”

“Eatingapieceofbreadandjamincamp,yournewestrecruitgetsstungonthetonguebyawasp”

“Youhearascreamfromyourneighbour’shouse,andrunningintotheirkitchenyoufindthebaby,aged18months,haspulledthekettleofboilingwateroverhimself,andhismother,whitetothelips,isrockingtoandfro.Shefallstothegroundasyougointotheroomandappearstobeunconscious.”

GuidesHandbook1946

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Complextrauma

‘Itisthesymptomsthatshoulddeterminethediagnosisnotthenatureofthetrauma(althoughtheremustbeone).ThedatahavesupportedourviewthatCPTSDshouldbedistinguishedbythetypeofsymptoms,notthetypeoftrauma’

(Brewin,26October,2017,emailcorrespondence).

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TIAsdefinedas….

•  ‘Systemdevelopmentmodelgroundedinanddirectedbyacompleteunderstandingofhowtraumaaffectsserviceuser’sneurological,biological,psychologicalandsocialdevelopment’(Paterson,2014)

•  TIservicescanbedistinguishedbytraumaspecificserviceswhichaimtotreattheimpactsoftrauma..

•  OriginatedintheUS:SAMHSA-establishedNationalCentreforTIC

•  InUK–Scotland’sMentalHealthStrategy(2012-2015),includespsychologicaltraumaaskeypriority.‘GeneralServicesshouldbetraumaaware’i.e.Primarycare,mentalhealthetc

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TIA:Keyprinciples

•  Recognition•  Resistretraumatisation•  Cultural,historicalandgendercontexts•  Trustworthinessandtransparency•  Collaborationandmutuality•  Empowerment,choiceandcontrol•  Safety•  Survivorpartnerships•  Pathwaystotraumaspecificcare

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Barriers….?

•  Focusonbiologicalbasisofmentaldistressratherthanhuman,familialorsocialissue

•  Focussingonsocialandsystemiccausesoftraumaplacespractitionersinoppositiontopowerfulgroupsandisthusavoided

•  Constantchangeandupheavalinservices,warinessandwearinessofnewinitiativesdwindlingresources..austerity

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Contexts•  Culture–asylumseekers,refugees,FGM•  Medicalsettings–Burntrauma,traumaticchildbirth•  Sexualviolence,abuseanddomesticviolence•  Childrenandfamilies•  Industrialandtransportationevents/disasters•  Terrorism–Tunisia,BoroughMarket,Brussels•  Hostagetaking•  Traumaticbereavementandloss•  Combatrelated-VeteransCovenant•  Civilandethnicviolence•  Workplacetrauma–emergencyservices•  Naturaldisasters

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Whatcontributestocomplexity…?•  Environment–social,economic,employment•  Previoushistoryoftraumaandabuse•  Lackofsocial/therapeuticsupport•  Reluctant/latehelpseeking•  Poorassessment,formulation,educationconcerningdevelopmentand

maintenanceofproblems•  Inadequate/poorprevioustherapeuticinput•  Multiple•  Poorexpectationmanagement•  Inflexibletherapeuticengagement•  Norelapsepreventionstrategies•  Nofollowup•  Chronicity•  Thesystem!

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Grenfell•  Traumaticlosses–life,home,

livelihood•  Exposuretosignificanttrauma•  Highlevelsofsubjectivelifethreat•  Culture,languageandmeaning•  Uncertaintyoverfuturesecurity•  Previouslossandtrauma•  Secondaryvictimisation•  Complexsupportarrangements•  Turfwarsandcompetingagendas•  Significantdisenfranchisement

frommainstreamsociety

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“Werecommendthatpublicsectoremployersshouldidentifyemployeesathigherriskofstressortraumaandproduceanationalframeworkwhichcoordinatessupportfortheseemployeesandestablishesclearaccountabilityfortheirmentalhealth.”

ThrivingatWork:TheStevensonandFarmerReviewofMentalHealthandEmployers,ThePublicSector,p.47,(October,2017)IndependentReviewofworkplacementalhealthneeds

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•  Isitanewphenomenon?•  Probablynot,but:–  focussedpsychologicalinterventionsinresponsetotraumaticlifeeventsareusedincreasinglymore

–  theapproachtoworkingwithindividualsaffectedbytraumaeventshasshiftedfrommorepsychodynamicwaysofworkingtoexposure-basedapproaches–systematic,in-depthprocessingofatraumatakesplace

–  thereforelisteningandwitnessingdetailedaspectsofatraumaticexperienceandtheaccompanyingemotionsareoftenanintegralpartofourwork

WhatisVicariousTraumatisation?

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•  PearlmanandSaakvitine(1995)describethephenomenonas‘…thecumulativetransformationintheinnerexperienceofthetherapist(orworker)thatcomesaboutasaresultofempathicengagementwiththeclient’straumaticmaterial’

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OrganizationalFactors•  Theresultscanbedeleteriouswhenorganizations:

–  Littleornorespiteforstaff(e.g.sharedcoverage,adequatetimeoff)

–  Unrealisticallyhighworkloads–  Failuretoprovideenoughqualifiedsupervision–  Denytheseverityandpervasivenessofapopulations’

traumaticexperiencesandtheirafter-effects–  Failuretoworkwithstafftoidentifyandaddresssignsof

vicarioustraumatisationorcumulativeexposure–  Noopportunitiesforcontinuingeducation–  Insufficientpostevent/incidentsupport

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! Overwhelmingevidencefrom30yearsofresearch–socialsupportisamajorprotectivefactorfollowinglifeevents/trauma

! Typesofsocialsupport–informational,practical,andemotional

! Typeofsocialsupportrequired–functionofcontextandindividualneeds–varyovertime;importanceofmatchingsupportprovisiontoneeds

Why provide support?

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GrowthFollowingAdversity–PostTraumaticGrowth(PTG)

•  Relationshipsareenhancedinsomeway–valuingfriendsandfamilymore,feelingincreasedcompassionandkindnessforothers

•  Changingviewsofoneself–havingagreatersenseofpersonalresiliency,wisdomandstrengthcoupledwithagreateracceptanceofvulnerabilitiesandstrengths

•  Changesinlifephilosophy–shiftsinunderstandingofwhatreallymatters,findingafreshappreciationofeachnewday,possiblechangesinspiritualbeliefs

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ThefutureofTIAinhealthandsocialcare…..

•  Raisingawareness•  Education•  Investment•  Politicalwill

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http://www.bbc.co.uk/programmes/b07yszwr

Relevantreading•  Sweeney,A.,Clement,A.,Filson,B.,Kennedy,A(2016)Trauma-informedmentalhealthcareinthe

UK:whatisitandhowcanwefurtheritsdevelopment?MentalHealthReviewJournal,Vol.21Issue:3,pp.174-192,https://doi.org/10.1108/MHRJ-01-2015-0006

•  Brewin,C.R.,etal(2017)AreviewofcurrentevidenceregardingtheICD-11proposalsfordiagnosingPTSDandcomplexPTSD.ClinicalPsychologyReview(2017),http://dx.doi.org/10.1016/j.cpr.2017.09.001\

•  Murphy,D.,Archard,P.,Regel,S.,andJoseph,S(2012)ASurveyofspecializedUKtraumaticstressservices.JournalofPsychiatricandmentalHealthNursing,doi:10.1111/j.1365-2850.2012.01938.x

•  Joseph,S.,Murphy,D.,andRegel,S(2012)AnAffective-CognitiveProcessingModelofPostTraumaticGrowth.ClinicalPsychologyandPsychotherapy,doi:10.1002/cpp.1798.

•  Dyregrov,A.,andRegel,S(2012)Earlyinterventionsfollowingexposuretotraumaticevents-implicationsforpracticefromrecentresearch.JournalofLossandTrauma:InternationalPerspectivesonStress&Coping,17:3,271-291.

•  JosephS.,MaltbyJ.,WoodA.M.,StocktonH.,HuntN.,RegelS.(2011)ThePsychologicalWell-Being-PostTraumaticChangesQuestionnaire(PWB-PTCQ):ReliabilityandValidity.PsychologicalTrauma:Theory,Research,PracticeandPolicy.August15,2011.doi:10.1037/a0024740

•  Regel,S.,andJoseph,S(2017)(2ndEd)PosttraumaticStress:TheFacts.OxfordUniversityPress,Oxford

•  Fernandes,A.,McDonnell,L.,Regel,S(2016)Editorial:Theroleofgeneralpracticeinfollowinguppatientswithtrauma.BritishJournalofGeneralPractice,January,2016,DOI:10.3399/bjgp16X683065

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