Updated: Nov 8, 2020
This is a topic that I have recently become inspired by and motivated to learn more about in my practice. To help cement my learning in this area, I thought I would reflect on my understanding. I will firstly explore vital concepts and understanding within the field, before considering the impact on practice.
Trauma can be caused by a number of stressors that reach beyond the obvious abuse and neglect; it can be the result of a dental procedure, or a concussion that causes significant shock to the body (Van der Kolk 2015). When our body experiences chronic stress, our cortisol levels increase, in order to enable us to respond to the perceived threat (Levine, 2015). However, in a highly anxious state, only basic functions are carried out, involving the nervous system survival response (eg. fight, freeze and flight) (Selye, 1976). If stressors continue, the body remains in high stress survival mode long after the stressor is gone. This puts constant stress on the body's systems (e.g. digestive system), making it difficult to function properly (Maté, 2011). This response is seen by those who have experienced adversity in early childhood, such as abuse, misattunement, attachment and chronic neglect during infancy.
Research indicates a link between adverse early childhood experiences and poor development, due to the impact of chronic stress on the body (Van der Kolk, 2015).
The Adverse Childhood Experiences study found that children who grow up in dysfunctional family environments - including those negatively impacted by alcohol, abuse, domestic violence or poverty - are at a greater risk of psychological distress in later life (Felitti et al., 2019). A young child is at risk of poor formation of neural pathways that support functioning and child development. A good example can be seen through an insecure attachment bond; a baby relies wholeheartedly on the primary caregiver to meet their every physiological and emotional need (Beck, 1969). If the parent has never had their own needs responded to as a child, they may lack the knowledge and skills to respond to that of their young.
There is concern that current health practices (especially those in inpatient settings) serve to reinforce these traumatic experiences, by rejecting and exerting significant control on clients (Muskett 2014). A good example in my own practice is sectioning. While based on ethical principles of maintaining the safety of those who are at high risk to self/other, they can serve to re-traumatise individuals, who are denied access to their basic human right of freedom of movement.
In particular, I have always found physical restraint/injection particularly difficult to consider, given the level of control implemented on scared and often traumatised clients.
Trauma-Informed Practice is grounded in an awareness and responsiveness to the impact of a trauma. This approach focuses on physical, psychological, and emotional safety, creating opportunities for empowerment, to develop a sense of control and safety (Substance Abuse and Mental Health Services Administration SAMHSA, 2014). Trauma informed services utilise a strengths-based approach, understanding maladaptive behaviour as related to trauma; facilitating changes in behaviour, through strengthening empathy, resilience and protective factors (Oral et al., 2016). Services should utilise a whole systems approach, including interventions and settings that reflect trauma informed care (SAMHSA, 2015). Mental health acute settings tend to reinforce maladaptive behaviour, since clients are only offered help (e.g. admission) when they present as high risk and engage in extreme self-harming behaviours.
As a service, we need to be trauma-sensitive and reinforce feelings of empathy and safety to build trust in professionals.
Sometimes admission is not appropriate, due to controls such as locked medication cabinets; these can serve to reinforce existing maladaptive behaviours on discharge. It is important that, as a team, we continue to provide regular community support, despite participation in negative coping strategies.
Lastly, I would like to identify the value of trauma informed care when working in learning disabilities [US: intellectual disabilities]. Many of my clients have experienced institutional neglect and abuse, with prolonged hospital stays and high levels of covert medication use (Department of Health, 2012). As a team, we now promote person-centred care in medication treatment planning, to support inclusion and avoid re-traumatising clients. This involves advanced decision treatment planning, to include client choice - when individuals are mentally well and able to make informed decisions around their treatment plan.
Bowlby J. (1969) Attachment. Attachment and loss: Vol. 1. Loss. New York: Basic Books.
Department of Health (2012) Transforming care: A national response to Winterbourne View Hospital. Department of Health Review: Final Report.
Felitti, V.J., Anda, R.F., Nordenberg, D., Williamson, D.F., Spitz, A.M., Edwards, V., Koss, M.P. and Marks, J.S. (2019). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. American journal of preventive medicine. 56 (6), pp. 774-786.
Levine, P.A. (2015) Trauma and memory: Brain and body in a search for the living past: A practical guide for understanding and working with traumatic memory. North Atlantic Books.
Maté, G. (2011) When the body says no: The cost of hidden stress. Vintage Canada. Related to physical disease
Muskett, C. (2014) Trauma‐informed care in inpatient mental health settings: A review of the literature. International journal of mental health nursing. 23 (1), pp. 51-59.
Selye, H., (1976) Stress without distress. In Psychopathology of human adaptation (pp. 137-146). Springer: Boston, MA.
Substance Abuse and Mental Health Services Administration (2014). SAMHSA’s concept of trauma and guidance for a trauma-informed approach. HHS Publication No. (SMA) 14-4884.
Van der Kolk, B.A. (2015) The body keeps the score: Brain, mind, and body in the healing of trauma. Penguin Books.