trauma informed approaches - nottinghamshire...journal of psychiatric and mental health nursing,...
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TraumaInformedApproaches
TraumaInformedCare:ImplicationsforPractice
D2N2TeachingPartnership,November,2018
[email protected]@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
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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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