Trauma-informed mental healthcare in the UK: what is it and how can we further its development?
| DOI | https://doi.org/10.1108/MHRJ-01-2015-0006 |
| Date | 12 September 2016 |
| Published date | 12 September 2016 |
| Pages | 174-192 |
| Author | Angela Sweeney,Sarah Clement,Beth Filson,Angela Kennedy |
| Subject Matter | Health & social care,Mental health |
Trauma-informed mental healthcare in the
UK: what is it and how can we further its
development?
Angela Sweeney, Sarah Clement, Beth Filson and Angela Kennedy
The authors’affiliations can be
found at the end of this article.
Abstract
Purpose –The purpose of this paper is to describe and explain trauma-informed approaches (TIAs) to
mental health. It outlines evidence on the link between trauma and mental health, explains the principles of
TIAs and their application in mental health and explores the extent to which TIAs are impacting in the UK.
Design/methodology/approach –The approach is a conceptual accountof TIAs including a consideration
of why they are important, what they are and how they can become more prevalent in the UK. This is
supported by a narrative overview of literature on effectiveness and a scoping of the spread of TIAs in the UK.
Findings –There is strong and growing evidence of a link between trauma and mental health, as well
as evidence that the current mental health system can retraumatise trauma survivors. There is also
emerging evidence that trauma-informed systems are effective and can benefit staff and trauma survivors.
Whilst TIAs are spreading beyond the USA where they developed, they have made little impact in the UK. The
reasons for this are explored and ways of overcoming barriers to implementation discussed.
Originality/value –Thispaper –authored by trauma survivorsand staff –describes an innovativeapproach to
mental healthservice provision that, it is argued,could have immense benefits forstaff and service users alike.
Keywords Mental health services, Childhood trauma, TIA, TIC, Trauma survivors, Trauma-informed
Paper type Conceptual paper
Introduction
It is known that many people in contact with mental health services have experienced physical or
sexual trauma (Mauritz et al., 2013), that there is a strong link between childhood trauma and
adult mental distress (Bentall et al., 2014), and that experiences of marginalisation, poverty,
racism and violence are correlated with poor mental health (Paradies, 2006). This has led to a call
for services to acknowledge psychological and social factors in the development of extreme
mental distress (Read et al., 2009). The hope is that such models would minimise the risk that
people presenting to services have their symptoms disconnected from the context of their lives.
In this paper, we will describe the concept of trauma-informed approaches (TIAs) which were
developed in North America but have relatively few published models from public services across
Europe. TIAs are based on the understanding that most people in contact with human services
have experienced trauma, and this understanding needs to permeate service relationships and
delivery (Harris and Fallot, 2001). We begin by examining the theoretical basis for TIAs including
the link between trauma and mental distress and institutional retraumatisation. We will argue for a
more systematic transformation of mental health services that acknowledges the role of trauma
in people’s lives and consequently reconceptualises relationships between survivors (people
who have experienced trauma and mental distress and who may use mental health services) and
Received 30 January 2015
Revised 11 June 2015
7 April 2016
Accepted 1 June 2016
© Angela Sweeney,Sarah Clement,
Beth Filson and AngelaKennedy.
Publishedby Emerald Group
PublishingLimited. This article is
publishedunder the Creative
Commons Attribution
(CC BY 3.0) licence.Anyone may
reproduce,distribute, translate and
create derivativeworks of this article
(for both commercialand
non-commercialpurposes), subject
to full attributionto the original
publicationand authors. The full
terms of this licencemay be seen at
http://creativecommons.org
/licences/by/3.0/legalcode.
Angela Sweeneyis funded by a
National Institute for Health
Research Post-Doctoral Fellowship.
This paper presentsindependent
research partially funded by the
National Institute for Health
Research (NIHR).The views
expressedare those of the authors
and not necessarilythose of the
NHS, the NIHRor the Department
of Health.
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VOL. 21 NO. 3 2016, pp. 174-192, Emerald Group Publishing Limited, ISSN 1361-9322 DOI 10.1108/MHRJ-01-2015-0006
service providers. Finally, we present a narrative overview of literature on effectiveness of TIAs,
map current TIA activity, explore why TIAs have not impacted on mainstream UK practice and
discuss what might be needed to bring TIAs to the UK.
Defining trauma
Definitions of trauma vary, but broadly, trauma refers to events or circumstances that are
experienced as harmful or life-threatening and that have lasting impacts on mental, physical,
emotional and/or social well-being (SAMHSA, 2014). Trauma can be a single event or multiple
events compounded over time. The concept of tra uma encompasses experiences of
interpersonal violence, such as rape or domestic violence. Complex childhood and
developmental traumas include community violence (e.g. bullying, gang culture, sexual assault,
homicide, war), abuse, neglect, abandonment and family separation (Van der Kolk, 2005;
www.nctsnet.org/trauma-types/complex-trauma). Lesser understood forms of trauma include
social trauma, such as inequality, marginalisation, racism and poverty, and historical trauma, the
trauma legacy of violence having been committed against entire groups, including slavery,
genocide and the Holocaust (Blanch et al., 2012). Lenore Terr (1991) has conceptualised two
basic types of childhood trauma: Type I trauma involves witnessing or experiencing a single event
such as a serious accident or rape. Type II trauma results from repeated exposure to extreme
external events, such as ongoing sexual abuse.
Prevalence of trauma
The Adverse Childhood Experiences (ACE) study investigated the association between childhood
trauma and adult health in over 17,000 people (predominantly white, middle class Americans;
www.cdc.gov/violenceprevention/acestudy/prevalence.html). Childhood trauma was common:
30 per cent of respondents reported substance use in their household; 27 per cent reported physical
abuse; 25 per cent reported sexual abuse; 13 per cent reported emotional abuse; 17 per cent
reported emotional neglect; 9 per cent reported physical neglect; and 14 per cent reported seeing
their mother treated violently (www.cdc.gov/violenceprevention/acestudy/prevalence.html).
Research has demonstrated that people in contact with the mental health system have
experiencedhigher rates of interpersonalviolence than the general population.A systematic review
estimated that half of those in the mental health system had experienced physical abuse (range
25-72 per cent) and morethan one-third had experienced sexual abuse (range 24-49per cent) in
childhood or adulthood, significantly higher than in the general population (Mauritz et al., 2013).
Similarly,survey research has foundthat people using mental healthservices are substantiallymore
likely to have experienced domestic and sexual violence in the previous year compared to the
general population (27 per cent of women and 13 per cent of men had experienced domestic
violence compared to 9 and 5 per cent, respectively, of the general population; 10 per cent of
women had experienced sexual violence compared to 2 per cent of the general population;
Khalifeh et al., 2015).
The link between trauma and mental health
Over the lastdecade, research evidencehas increasingly supportedthe notion that trauma is linked
to adult psychosis and a wide range of other forms of mental distress (e.g. Bentall et al.,2014;
Fisher et al., 2010; Kessler et al.,2010; Paradies, 2006; Varese et al.,2012). The ACE study found
that the moreadverse life events peopleexperience prior to the age of18, the greater the impact on
health and well-being over the lifespan, including poor mental health, severe physical health
problems, sexual and reproductive health issues, engaging in health-risk activities and premature
death (Andaet al., 2010). Similarly, Shevlinet al. (2008) found that experiencingtwo or more trauma
types significantly increased the likelihood of experiencing psychosis. Dillon et al. (2012) report
evidence of a dose-dependent relationshipbetween the severity, frequency and range of adverse
experiences and subsequent impact on mental health. Interestingly, research has also
demonstrated that the general public share the notion that trauma and adverse life events play a
causal role in mental health difficulties (e.g. Read et al., 2013; Angermeyer and Dietrich, 2006).
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