What happened to you? How health & care can become trauma informed
By Liz Durrant
When I first started my career in the mental health sector it struck me that our system didn’t work very well for people with a history of trauma, especially those who are given a diagnosis of Emotionally Unstable Personality Disorder. As my time across the NHS and social care sector has extended, so has my understanding and experience of how the system helps and hinders people with a history of psychological trauma. I’ve seen people who need our support, staff who try to help and surrounding systems all struggle to find a way to adequately serve this group of people. I’ve reached the conclusion that the way we are working isn’t working and we need a trauma revolution to sort it out.
Before we agree a solution, we need to understand the extent of the issue. The prevalence of those who have experienced psychological trauma is hard to pin down; it is not a concept we traditionally define and use in everyday support. Instead I would ask mental health workers to consider how many people you are supporting right now who have experienced some form of psychological trauma in their life? How many people suffered a violent or abusive childhood, have experienced domestic violence, horrific tragedies or sexual assault? I imagine quite a few.
The way we are working isn’t working and we need a trauma revolution to sort it out.
In the UK we haven’t defined psychological trauma and how best to support people who have experienced it in a unified way. It can broadly be defined as the impact of an event (or events) where there was a perceived or real threat to life, body or sanity. Psychological trauma occurs when the person's ability to integrate that experience emotionally is overwhelmed and therefore processing doesn't happen as it usually would. We do not have agreed therapeutic approaches to supporting people who are psychologically traumatised, unless they have received a diagnosis relating to how their experience is affecting them, for example through diagnoses such as Emotionally Unstable Personality Disorder, Post Traumatic Stress Disorder, Anxiety or Depression. In other words, the way in which abuse and trauma makes you feel and react must be defined as a ‘mental health condition’ before you can receive therapeutic, biological and social support through our current system.
As well as needing to have your distress understood in the context of illness to access support, when you get support, it is highly likely the system will unintentionally re-traumatise you. Our current system is not built on foundations of psychological safety for our staff or people we support. Our provision of therapeutic interventions such as Dialectical Behavioural Therapy is woefully under-resourced. Our environments are not focused on healing and limiting violence and our use of control through restraint, seclusion, rapid tranquilisation and the Mental Health Act continues to rise. People we support feel judged, misunderstood, re-traumatised and unsafe and our staff feel burnt out, unable to help and silenced.
The way in which trauma makes you feel must be defined as a ‘mental health condition’ before you can receive therapeutic, biological and social support through our current system.
We also appear to lack compassion and empathy for people’s pain, our language being the most obvious indicator of this. We are describing people using stigmatising terms as ‘frequent flyers’ and ‘revolving door patients’ as if they just love spending time in an inpatient ward. In mental health teams you hear people described as a label instead of a person in distress. Instead, could we begin from a place of understanding and empathy? Could we build a national approach which enabled healing and, perhaps most critically, supported staff to remain compassionate and have the time and tools to help?
What we are doing isn’t working. Not for people in distress, staff, the system or public finances. We need to try something different. To start with, we need to be talking about trauma and being trauma informed.
We are describing people using stigmatising terms as ‘frequent flyers’ and ‘revolving door patients’ as if they just love spending time in an inpatient ward.
Perhaps people with lived experience, professionals and leaders from across health and social care could agree together what we mean by psychological trauma and what we want to do (and not do) to help those who have experienced it. This could involve evidence about what does and doesn’t work as well as enabling people’s voices and stories to be heard and acted upon. Then perhaps we can understand how we might transform our system, so that it stops re-traumatising people and helps them to heal and recover.
One potential argument against such an approach could be the lack of money. My response to this is that we are already spending money on people who are psychologically traumatised. They are people accessing mental health care right now with a variety of diagnoses. They have been admitted to inpatient care, sent to high cost placements and are sitting in locked rehabilitation wards away from their home. They are turning to A&E as a last resort. They are homeless, in prison, moving between supported living services and receiving support for the impact of the substances they use to dull the pain. And we are letting them down.
Could we build a national approach which enabled healing and, perhaps most critically, supported staff to remain compassionate and have the time and tools to help?
Somewhere along the way, our system has lost its ability to ask, ‘what happened to you?’ instead of asking ‘what’s wrong with you?’. Arguably, this is born out of a desire to help people recover and a need to turn people’s distress into something we can ‘fix’. When we are unable to fix someone’s pain as caring professionals, we resort to cutting off, blaming the individual and building higher walls of defence. Those who build such mechanisms are not ‘bad people’, they are human and struggling to watch another human in pain. Therefore, perhaps our trauma revolution needs to begin with compassion; compassion for people who have suffered such abuse and distress; compassion for our staff working to support them and, most fundamentally, compassion for ourselves.
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