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Exploring trauma care

20 September 2021

Practice development nurse and health visitor Christopher Sweeney looks at what trauma-informed practice means to health visiting. 

The association between trauma and adverse health outcomes is well known. Felitti et al’s (1998) adverse childhood experience (ACE) study was the first to formally identify a gradient between 
exposure to trauma in early life and increased risk of poor health in adulthood. In Scotland, one in seven adults report having undergone at least four of the traumatic events now known as ACEs (Marryat and Frank, 2019). See A definition of trauma below.

Trauma-informed care is not an intervention to ‘cure’ those who have experienced trauma. Instead, it is a shift towards recognising the prevalence of trauma, and asks us to consider how to better support those who have had traumatic experiences (Sweeney et al, 2016).

Such an approach has been termed ‘taking a trauma-informed lens’ (see Seeing through a trauma-informed lens below). In order to achieve this, health services should move from asking ‘What is wrong?’ and instead ask ‘What has happened?’ (Substance Abuse and Mental Health Services Administration, 2014).

Key principles of trauma-informed practice

In March 2021, Scotland’s National Trauma Training Programme published a toolkit to support services to become trauma-informed. The toolkit references Fallot and Harris (2006), who identify five key principles of trauma-informed practice that can all be adapted for use in health visiting.

1. Safety

First impressions matter – we can make children and adults feel safe by how we present and introduce ourselves. Health visitors can have difficult and upsetting conversations with parents, and being trauma-informed means being attuned to the unease this can cause. Offering clear explanations as to why certain questions are asked mitigates the risk of re-traumatisation (see Re-traumatisation below).

An example is routine sensitive enquiry. Being trauma-informed means not simply asking whether a woman is experiencing gender-based violence (GBV). Instead, HVs set the scene by explaining that GBV is one of the health topics discussed during first visits in Scotland. We explain that many women experience emotional, sexual, financial or physical abuse during their lifetime, and that all women are routinely asked about this on a HV’s first visit as abuse can affect their health, and the health of their baby.

2. Trustworthiness

Set reasonable expectations about what you can and can’t do. As HVs, we ensure the information and advice offered is evidence-based (NMC, 2004). Explaining confidentiality, and when and in what circumstances we have a duty to share information, helps to set boundaries within the HV-parent relationship.

In some circumstances, parents may feel that the service is breaching their trust, such as when sharing child protection concerns with authorities. Transparent dialogue before any intervention takes place can mitigate the risk of re-traumatisation and reduce the risk of the parent losing trust in HVs or the service.


A definition of trauma

The Substance Abuse and Mental Health Services Administration (2014) defines trauma as ‘an event, series of events, or set or circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional or spiritual wellbeing’.


3. Choice

An important step towards trauma-informed care is to consider why someone may be unable to engage with a service or disengages from it. Offering examples from her experience as a mental health nurse, Portman-Thompson (2020) shares how a sense of powerlessness – caused by strict appointment times or by meeting unfamiliar staff – has resulted in patients becoming re-traumatised.

HVs should offer a choice in how and when appointments take place, and aim to provide continuity of care. Some women prefer a female to visit their home, and therefore male staff in HV teams should ask whether the mother they plan to visit has a gender preference.

A key component of the SCPHN role is the search for health needs (NMC, 2004). For this approach to be trauma-informed, we should refrain from suggesting or offering advice on what children and families need, and instead offer information on what support or services are available (Waite et al, 2010).

An important step towards trauma-informed care is to consider why someone may be unable to engage with a service

4. Collaboration

HVs act as gatekeepers to services and support, and need to recognise the power imbalance between health professionals and families. HVs can take steps to reduce this power imbalance by recognising the patient is the expert of their own experience and ensuring we do things ‘with’ someone instead of ‘to’ or ‘for’ someone. Collaboration should also take place between staff – strong links between multi-agency teams make it easier to facilitate referrals and to ensure parents and children receive the support they need.

The toolkit makes it clear that leaders must provide staff with protected space and time for informal peer support, as this can help buffer the impact of vicarious trauma. However, the move away from office-based working during the Covid-19 pandemic has limited this, as remote working offers fewer opportunities for spontaneous conversations during and at the end of the working day.  


Case study

Christopher Sweeney writes:

John* has a history of non-engagement with services and has missed many appointments. I am unable to contact his mother Sarah to discuss a recent missed hospital appointment and decide to carry out an unscheduled visit to his home. When I visit, Sarah becomes very upset, standing up and shouting that I think she is a bad mother, saying she will not allow social services to take her children. I have known Sarah for over a year and this response is out of character. Being trauma-informed meant I recognised there may be a reason for this response. I speak softly and calmly, apologising for upsetting her, allowing Sarah to return to within her window of tolerance.

Sarah explains a relative had a child removed from their care and that Sarah thinks about this often. This is the first time Sarah has shared this information, and offers an explanation as to why she is reluctant to engage with professionals. During the visit, Sarah consents to a second hospital appointment being made, and for me to visit her home a couple of days before the appointment to remind her and discuss her plans for attending the hospital.  

*All names have been changed to ensure confidentiality 


5. Empowerment

A person-centred, strength-based approach recognises that people are resilient and have the ability and skills to recover from trauma. It is important to be present in each contact with families, and validate their feelings when they share concerns.

Staff should be empowered to look at their service and consider what changes can be made to help them be trauma-informed. HVs are leaders, and they can empower the colleagues and families that they work with by modelling trauma-informed behaviours.

People who have experienced trauma can be ‘triggered’ by stress and find themselves outside their window of tolerance. Acting in a trauma-informed way can empower them, and HVs, to stay within their window of tolerance (see panel below). HVs can use parenting techniques such as the Solihull Approach to help children to regulate their emotions and thereby stay within or return to their window of tolerance (Douglas and Brennan, 2004).


Re-traumatisation

Re-traumatisation is when a person experiences something that triggers the memory of a traumatic event, thereby provoking the same response as that traumatic event. - Portman-Thompson, 2020


Conclusion

As the NHS starts to enter the post-Covid-19 recovery stage, there is a need for leaders to recognise the benefits of informal peer support for staff to mitigate the impact of experiencing vicarious trauma. This is something to be aware of, especially for those office-based staff who are slowly returning to NHS buildings following a prolonged period of home-working.

While some HV practices – such as reporting child protection concerns to social services, or carrying out an unscheduled visit to a child – may cause additional trauma or re-traumatisation to children and families, a trauma-informed approach will increase the likelihood that parents trust us and our services, and encourage them to reach out for support at an early stage. Acting in a trauma-informed way is therefore a means of mitigating the risk of future trauma.

A trauma-informed approach is an open, empathetic and empowering one, and in reality this is the type of good care HVs provide as part of their everyday practice. This toolkit offers HVs the opportunity to reflect upon their own practice and to recognise the positives while identifying how to make changes to become trauma-informed.  


Window of tolerance and regulation

The ‘window of tolerance’ (Ogden et al, 2006; Siegel, 1999) is the state in which we can tolerate our feelings without becoming stressed, distressed, and overwhelmed. We all need to be in this state (also called the ‘optimal arousal zone’) to maintain our wellbeing. If we stray outside of this zone and become hyper- or hypoaroused, we have exceeded our tolerance level and need to return to the `window of tolerance’ state, according to Trauma-informed practice: a toolkit for Scotland-
Homes and Grandison, 2021


References

Douglas H, Brennan A. (2004) Containment, reciprocity and behaviour management: preliminary evaluation of a brief early intervention (the Solihull Approach) for families with infants and young children. International Journal of Infant Observation 7(1): 89-107.

Fallot R, Harris M. (2006) Trauma-informed services: a self-assessment and planning protocol. In: Homes A, Grandison G. (2021) Trauma-informed practice: a toolkit for Scotland. See: gov.scot/publications/trauma-informed-practice-toolkit-scotland/documents (accessed 29 July 2021).

Felitti V, Anda R, Nordenberg D, Williamson D, Spitz A, Edwards V, Koss M, Marks J. (1998) Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. American Journal of Preventative Medicine 14: 245-58.

Homes A, Grandison G. (2021) Trauma-informed practice: a toolkit for Scotland. See: gov.scot/publications/trauma-informed-practice-toolkit-scotland/documents (accessed 29 July 2021).

Marryat L, Frank J. (2019) Factors associated with adverse childhood experiences in Scottish Children: a prospective cohort study. BMJ Paediatrics Open 3: 1-7.

NMC. (2004) Standards of proficiency for specialist community public health nurses. See: nmc.org.uk/globalassets/sitedocuments/standards/nmc-standards-of-proficiency-for-specialist-community-public-health-nurses.pdf (accessed 15 July 2021).

Ogden P, Minton K, Pain C. (2006) Trauma and the body: a sensorimotor approach to psychotherapy. Norton: New York.

Portman-Thompson K. (2020) Implementing trauma-informed care in mental health services. Mental Health Practice 23(3): 34-41.

Siegel DJ. (1999) The developing mind. Guilford: New York.

Substance Abuse and Mental Health Services Administration. (2014) SAMHSA’s concept of trauma and guidance for a trauma-informed approach. SAMHSA: Rockville, MD. See: https://ncsacw.samhsa.gov/userfiles/files/SAMHSA_Trauma.pdf (accessed 21 July 2021). 

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): 174-92.

Waite R, Gerrity P, Arango R. (2010) Assessment for and response to adverse childhood experiences. Journal of Psychosocial Nursing and Mental Health Services 48(12): 51-61.

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