Mainstreaming Trauma: Developing “Trauma-Informed Services” Dr Keith Brown

Why focus on trauma? It is common Using DSM IV PTSD criteria, over 50% of the US population exposed to traumatic events Lesser degrees of traumatisation even more common But little information available on the Scottish population

Why focus on trauma? It can lead to mental and physical ill health, but not in everyone exposed Lifetime prevalence of PTSD estimated 5-6% (male) and 10-12% (female) In a traumatised population increased incidence of mood disorders, suicidality, substance misuse, personality disorder, dissociative disorders, psychotic disorders, self-harm, eating disorders and anxiety disorders

Why focus on trauma? ECA study found traumatised children had increased risk of developing the mental health problems above AND heart disease, cancer, chronic lung disease, liver disease, HIV/AIDS as well as social problems of homelessness, prostitution, delinquency, criminal behaviour and unemployment Clear dose effect

What happens to trauma survivors? Not all develop PTSD or other problems Transitional probability effected by genetic factors, temperament, adverse childhood experiences, pre-existing mental disorder, low socioeconomic and educational status If PTSD does develop it is often chronic, undetected, and untreated or incorrectly treated (Wang et al, 2007)

How common is trauma in service users? In USA, many studies- 98% of public health clients exposed to at least one traumatic event - 43% (119/275) satisfied criteria for PTSD, but in only 2% (3/119) had this been previously diagnosed (Mueser et al, 1998) 75% of women in substance misuse service (SAMHAS/CSAT, 2000) 80% of female offenders with mental illness (Smith, 1998)

How common is trauma in service users? 97% of homeless women with mental illness (Goodman et al,1997) 82% of adolescents in an inpatient setting (LeBel et al, 2004) 51% of State Hospital female patients had history of CSA (Craine et al, 1988) 67% of female outpatients had history of abuse (Muenzenmaier et al,1993)

How common is trauma in service users? In Scotland little data Preliminary survey in Tayside Psychological Therapies Service found of approximately 5500 referrals 330 had primary PTSD/trauma problem and 730 had a secondary PTSD/trauma problem (Prof K Power) No data on inpatients

What should be done? In the USA increasing view that the traumatised population not a subgroup, but rather a majority of public mental health clients And that ignoring this and failing to address trauma issues has implications for services and costs incurred What is the situation in Scotland?

What should be done? Harris, M & Fallot, R (eds) (2001) Using trauma theory to design service systems (New Directions for Mental Health Services Series). San Francisco: Jossey-Bass Stimulated the development of “Trauma-informed Services” In 2005 The National Centre for Trauma-informed Care established

NCTIC “A trauma-informed approach is based on the recognition that many behaviours and responses … are directly related to traumatic experiences that often cause mental health, substance misuse, and physical health concerns. For many consumers and survivors, systems of care perpetuate traumatic experiences through invasive, coercive or forced treatment that causes or exacerbates feelings of threat, lack of safety, violation, shame and powerlessness”

NCTIC “Trauma-Informed Care (TIC) provides a new paradigm under which the basic premise for organising services is transformed from “What is wrong with you” to “What has happened to you” All components of the care system have to be reconsidered in the light of an understanding of the role that trauma plays in the lives of those seeking care

Trauma-Informed Care Not designed specifically to treat symptoms Sees symptoms as consequence of underlying trauma Designed to understand clients in the context of their life experiences and history Avoids re-traumatisation Focussed on patient understanding and skills building Requires redesign of services All staff require skills in trauma assessment

Trauma-Informed Care Four key concepts- Power & control –focus on empowerment Psycho-education –reframing current symptoms as attempts to cope with past abuses Goals of promoting a safer environment and a better life, not just symptom reduction Language -should convey message that staff don’t view clients as impaired cases, also avoid jargon

Trauma-specific Services These are specialist services designed to treat the actual sequelae of trauma They help inform, support and supervise the “Trauma-Informed Service” Use best-evidence/ evidence-based guidelines to inform treatment interventions

Examples Numerous models in the USA such as Sanctuary Seeking Safety Model Trauma Adaptive Recovery Group Education and Therapy (TARGET) Addictions and Trauma Recovery Integration Model (ATRIUM)

BUT… To date most have little supportive evidence Morrisey J, Jackson E et al (2005). Twelve-month outcomes of trauma-informed interventions for women with co-occurring disorders. Psychiatric Services, 56(10) 1213-1222.

BUT…….. They at least acknowledge and try to tackle a very real problem which Scottish services on the whole haven’t in the same systemic way

SO….. Should we follow the Trauma-Informed Care model? If so, from a national perspective what are the gaps in the current service provision? If not what alternative approach should we use? What training requirements will there be?