What is the purpose of this guidance?

This guidance supports people working in mental health, learning disability and autism inpatient settings to make services more trauma-informed and harm-aware.

It is 1 of 3 approaches which will support the practical implementation of the Culture of care standards for mental health inpatient services:

• trauma-informed and harm-aware inpatient care (this guidance)
• Autism-informed inpatient care
• Culturally competent inpatient care

What is trauma-informed care?

Trauma-informed care is a whole system approach that recognises, understands and responds to both the prevalence and impact of trauma (and adversity) in a way that seeks to cause no further harm.

In inpatient care, this means focusing on consistent and trusting relationships that help trauma survivors to feel connected, safe and able to heal from their experiences.

It means offering a range of trauma-specific support and interventions, providing a safe and welcoming environment and all staff being trained in trauma and confident in how to respond compassionately.

It means wards becoming harm-aware, and thoughtful and reflective about ways to avoid harm.

What trauma-informed care is not

Despite current enthusiasm for trauma-informed care, it is not yet clear whether experiences or outcomes are meaningfully changing for trauma survivors.

There is also some concern that ‘trauma-informed’ has become a way to deny access to care.

Therefore, we must consider what trauma-informed care is not. Trauma-informed care is not:

• a repackage or rebrand of business as usual
  • it requires significant cultural change supported by senior leadership, with existing practices challenged and constant reflection
• a dogmatic approach which means thinking every patient has experienced trauma or refusing to acknowledge and respect other understandings of mental distress or illness, including those linked to loss
• a way to legitimise neglect of people given a diagnosis of ‘personality disorder’, denying them access to hospital care or life-saving interventions
• a means of forcing positive risk-taking without people’s consent, or presuming those given a diagnosis of ‘personality disorder’ have ‘capacity to end their life’
• an opportunity to idly discuss the most personal aspects of a patient’s life
  • people’s right to privacy and control over their history and information is paramount
  • any formulation of a patient must be done with them and not to them
• a reason to employ the historical, simplistic, stand-alone categories of trauma
  • instead, the complexity of people’s lives and the multitude of experiences that can be traumatic are recognised
• something that can be achieved through tasks and checklists alone
  • it requires focus and attention on relationships and being alongside people in distress

Why trauma-informed care is needed

Improved experiences, outcomes and environments

Trauma-informed care is associated with improved mental health outcomes, patient satisfaction, and significant reductions in violence, substance abuse, containment-related injuries, seclusion and restraint and the use of sedative-hypnotics in acute inpatient settings.

Responding to prevalence of trauma in people who need hospital care

It is broadly accepted that mental health is determined by a combination of factors that are:

• biological (for example, genetics and physical health)
• psychological (for example, beliefs, perceptions and previous traumas)
• social (for example, relationships, culture and life circumstances) factors

Many people who need inpatient mental health care will have experienced significant trauma and adversity in their lives. For some, there will be a direct relationship between this trauma and the distress or symptoms that have led them to need hospital care.

For example, research indicates that many people admitted for mental health inpatient care were physically or sexually abused as children; that people who have experienced racial trauma or other forms of discrimination are more likely to develop unusual or paranoid beliefs (‘delusions’) or experience crisis admissions; and many displaced people experience mental health issues related to the traumas they have been through.

Despite this well-established link, some people report that they are only seen as being mentally ill and never asked about their trauma histories or offered trauma-specific interventions.

Others are seen as traumatised but not mentally ill, and denied access to services that could help them. The physical impacts of traumatic experiences are also often not identified or considered. For example, in forensic services, many women have traumatic brain injury, often from repeated domestic violence.

Avoiding further trauma and harm through hospital care

Both the outcomes and the experiences of trauma survivors accessing hospital care are poor.

Rather than providing a safe and therapeutic space to stabilise and heal, inpatient care is often traumatic in itself and can cause further harm.

The nature of inpatient care leaves people vulnerable to traumatisation from restrictive and coercive practices, such as being sectioned, psychological and physical restraint, forced medication, rapid tranquilisation and seclusion.

Research has shown that certain groups of people, such as those from ethnic minority communities, autistic people and people with a learning disability, are more like to experience restrictive practices than others.

There are also many less obvious sources of traumatisation, including:

• effects of medication
• issues relating to diagnosis:
  • silencing people’s stories through diagnosis or what is written in their record
  • the risks of diagnostic overshadowing (that is, when symptoms of physical illness are attributed to a person’s mental illness)
  • discriminatory practice associated with the diagnosis of borderline or emotionally unstable personality disorder
• lack of understanding and knowledge of dissociative experiences, trans-inclusive care, autism and neurodivergence
• punitive or behavioural responses to self-harm and suicidality
• a lack of therapeutic relationships

The day-to-day harms from being in an inpatient environment can include:

• facing indifference to pain and suffering
• no voice or choice in care
• no access to outdoor spaces or the things, food and people that the person finds comforting
• the person not being believed about what they are experiencing
• suicidality being dismissed
• the environment being a trigger

Supporting the workforce

Many staff in mental health services will have their own experiences of trauma and adversity and, at times, may find it painful and traumatising to be alongside extreme human distress or experience moral injury when they are involved in or witness care that causes harm or trauma.

A systemic approach to trauma-informed care can therefore support staff wellbeing, satisfaction and recruitment and retention.

Delivering trauma-informed care

Trauma-informed care into practice

The following approaches may be useful for teams to consider, working in partnership with people with lived experience of trauma and adversity.

Each recommendation is accompanied by an example of what this could look like in practice for a patient as written by a person with lived experience of inpatient care.

Focus on the relationship between patients and staff

Staff are supported to build and make space for personalised, supportive and trusting relationships with patients.

This is enabled by a workforce that is representative of the people it supports and that can meet the needs of every patient, including:

• peer workers
• trauma-trained therapists
• independent domestic violence advisors
• culturally competent advocates
• people who can offer housing and benefits support

Train staff to be trauma-informed

All staff are trained in trauma-informed approaches, including listening and validation and co-regulation.

Effectively support staff

Reflective practice and clinical supervision are in place to ensure staff are well supported and emotionally available to be alongside trauma survivors in a safe, compassionate and containing way.

Create a trauma-informed environment

Staff work with patients and carers to create trauma informed environments that are safe, soothing and welcoming – supporting patient and staff wellbeing.

Ward environments are adapted (thinking about sight, sound, smell, taste, touch, temperature, proprioception, interoception and pain) to meet the needs of those admitted.

This includes cultural, disability and sensory needs (particularly for autistic people and trauma survivors), ensuring the environment enables everyone to access the care they need and prevents adverse health outcomes.

Co-produce care plans that are trauma-informed

Staff listen to patients and their support networks to plan and deliver care that respects to their wishes, needs and past experiences, and prioritises build therapeutic relationships

Avoid blanket approaches to safety

Empower and train staff in taking a more personalised approaches to supporting people to be and feel safe, including a more a compassionate response to self harm.

The recently published ‘Staying safe from suicide: Best practice guidance for safety assessment, formulation and management‘ offers further advice and guidance.

Value patient experience

Create multiple ways to hear and value the experiences of patient and families and use them to improve care.

Further points for staff to consider when developing a trauma-informed response

Beth Filson, a trauma survivor and trauma-informed care consultant, suggests staff need to consider the following:

• Expect trauma: see people in the context of their life history and the complex experiences they have had, rather than through the lens of their diagnosis.
• Culture matters: consider the organisational and systemic culture you work in. How do people in distress experience that culture through every interaction? What has the culture of the mental health system taught people about themselves, their needs, and how safe it is to ask for help? Could how we speak about people and their experiences increase feelings of shame or powerlessness?
• Check your power: Could our own characteristics and the way we interact with a person in distress trigger or add more stress? Make sure all staff have space to reflect on the power and privilege inherent in their roles as clinicians: they have the keys to get out, to hold the pen in writing notes, to discriminate against people with a particular diagnosis, and to decide the credibility of a person’s testimony.
• Consider the environment: This has a powerful influence on distress. It can support regulation and calm people, or it can support dysregulation and the fight, flight and freeze survival responses.
• Create the opposite as an antidote: Trauma is the experience of loss, neglect, violation, betrayal and powerlessness. The antidote is the experience of safety, trust, voice, and choice and collaboration.
• Relationships matter: Relationships can be the source of trauma and of healing. Being present alongside people in their distress and bearing witness to what they have suffered without judgment demonstrates compassion and fosters connection.
• Trauma-specific support and therapy: While this is a whole system approach, capacity is needed to deliver a trauma-specific offer that gives people hope that they can heal from their experiences.
• Do no harm: Be aware that mental health services can cause harm and strive to avoid causing further harm.

References

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Publication reference: PRN01727_iii