Trauma-Informed?

​​Working within a trauma-informed approach (TIA), gives rise to necessary consideration of the environment or service ‘umbrella’ under which one is expected to deliver such a framework. Research evidences the cumulative burden of adversity on increasing risk for many negative outcomes, such as mental illness and a response in many service sectors has been to consider invoking concepts of trauma and adversities in policy and practice.  In my career as an Occupational Therapist, I predominantly worked in Child and Adolescent Mental Health and Forensics in the public health system.  In more recent years, I gained qualifications as a Psychotherapist and I now work mainly with ACC Sensitive Claims individuals.  I want to discuss the response and extent to which I have experienced these services to work within overarching principles of TIA firstly as an Occupational Therapist, and secondly as a Psychotherapist within what can be regarded as an insurance-based model to trauma care.  Briefly, it is important to outline the principles that a TIA is based (for more information see Te Pou Te Pou o te Wakaaro Nui: Trauma informed care, 2018).  TIA aims at creating a culture that embodies the following –  

safety; trustworthiness and transparency; peer support; collaboration and mutuality; empowerment, voice and choice; and understanding cultural, historical and gender issues.

Perhaps simple concepts, however the filtering of these concepts into the workplace setting is perhaps where things become more complex.  These principles have parallels with what I see as humanistic and existential perspectives as oppose to ground-breaking, innovative research. They are highly relevant when considering the disintegration and fracturing impact of experiencing trauma and what is needed for the healing and the repair of the individual.  These principles are not referring to behaviour or labels imposed, stereotypes, definitions, or other preconceived categories that individuals are sometimes expected to subjectively ‘fit’.  I believe it is asking for the authenticity of connecting with the other.  Curiously, this is a big expectation for those working in mental health it would seem.

Awareness around the stigma and the negative attitudes held by mental health staff towards those who experience mental illness, is increasing (Martensson, Jacobsson & Engstrom, 2014).  Criticism, assumptions, opinions and judgement from clinicians was common, when I was working in various Child and Adolescent Mental Health settings.  The attitudes of staff towards the families with adversity, peppering most clinical presentations, felt almost like an inconvenience.  A familiar theme in their research, Berliner & Kolko (2016:169) offer –

instead of characterizing children with problems as intentionally misbehaving, it is important to consider that the behaviours may be adaptive or understandable responses to adversity or other historical influences

Another consideration highly relevant to child and adolescent services, is the support necessary not only to the person the referral to services concerns, but the supporting persons of that individual who are also often impacted by trauma experiences themselves.  This is intergenerational trauma or trauma repeated over generations.  This is seen often when working with families and the clinical thinking necessary is more systemic.  This was emphasised by Figley & Figley (2009:174) who recognised the pervasive nature of trauma whereby –

the traumatised person who has a good result from linear treatment is surrounded by supporters who are still traumatised (secondarily) themselves, and who remain ordered around the traumatised person without benefit of reconstructing and processing through the traumatic experience

It is therefore seen that a certain level of disconnection exists between the needs of traumatised individuals and their families and implementing TIA within overall constraints of service provisions, expectations and budgets.  Time is required by the clinician seeing the individual referred, to gather the personal information from all family members concerned, with a gentle, inquisitive manner.  This requires often, considerable time that services are often faced as not having the luxury of providing.  It can often feel as though services repeatedly attend to individuals when in crisis, rather than providing an overall ethos of care and healing – or the ‘ambulance at the bottom of the cliff’ approach (Figley & Figley, 2009). 

Not only are services responsible for constraints and limitations to implementing TIA, so are individual clinicians. The overall culture of a working environment is implicitly instrumental in incorporating TIA into policies for positive change. Aaron and colleagues (2006) note that the workplace culture and climate will influence clinician’s attitudes and further add that a “more positive organizational climate is associated with better organizational process, work attitudes, and outcomes of mental health services” (Aaron, et al., 2006, p. 2-3). Of interest but of no surprise, Baker et al., (2016) found that staff attitudes can effectively act as a roadblock to the implementation of new approaches to mental health care.  For all staff involved within TIA services, Clark, et al. (2015) reminds us as the importance in recognising transference and countertransference within the relationship.  Perhaps this offers a reason for the staff who show unwillingness or inability to adopt a TIA perspective.  Given the prevalence of childhood adversity, such as childhood sexual abuse (Ministry of Justice, 2015), it would stand to reason that a number of employees in the field of mental health, are likely to have their own journey or know of a close friend/family member perhaps yet to embark on their journey and acknowledged their own therapeutic needs.  I see transference and countertransference as highly relevant for staff and their relationships with clients in mental health settings, although it is an intangible concept that is perhaps not easily ‘taught’.  Martensson et al., (2014:787) state that –

staff do not only need knowledge, information and education, but also to be involved in supervision and processes that actively highlight and challenge their own beliefs and attitudes

 

Horsfall et al. (2010:453) offer that “avoiding discussions of shame or stigma could relate to the professionals’ own views about mental illnesses”.  This has been supported in the literature with Hansson et al., (2013) findings revealed that staff who were treating patients with a psychosis or working in inpatient settings presented with the most negative attitudes. Clark, et al., (2015:6) reiterates that –

acknowledging the impact of trauma requires that the trauma-informed provider adjusts how care is delivered in order to accommodate what the trauma survivor needs—and to deliver it in such a way that the survivor’s sense of safety is prioritized

When consideration is given to the implementation of trauma-informed approaches into mental health care – and perhaps along with other settings – the staff that this is directed at, needs to be a part of the ‘package’ of delivery. 

Sweeny, et al., (2016:177) again thoughtfully offers –

Staff who experience conflicts between job duties and their moral code are under chronic stress for which they must learn to cope and adapt. Those coping strategies may include “shutting off” the ability to empathise, and viewing people receiving services as “other” thereby disqualifying their humanity and basic human rights

It has to be said though also, that encouragingly, literature has revealed that by providing training on trauma informed initiatives, not only does this build staff knowledge, it can also influence change in attitude, develop compassion and positive practices reflecting TIA (Schiff, et al., 2017; Brown, Baker, & Wilcox, 2012).  I would hasten to add that because we are talking about layers of complexities within most individuals including staff working in mental health, I would expect this to vary considerably dependent on each unique setting.

Te Pou o te Whakaaro Nui is a national centre of evidence-based workforce development for the mental health, addiction and disability sectors in New Zealand.  The work of Te Pou within trauma-informed care, amongst other areas, has provided rationale, recommendations and a framework designed to be integrated into mental health delivery in New Zealand.  It is evidenced and echoes other leading sources of trauma-informed care and research, such as the Substance Abuse and Mental Health Services Administration (SAMHSA) in America, with careful adaptation to ensure it is culturally respectful to Maori. One may want to therefore question the ethics surrounding resistance to implementing trauma-informed care within such vastness of research, evidence and current efforts. Continuing to not meet the individual needs within our services effectively mirrors, repeats and reinforces the unmet needs of the individuals seeking care.  Bryson and colleagues (2017) importantly describe an emerging theme of change needing to occur at a deeper level within an organisational culture, for implementation of TIA to be successful.  Somewhat of a parallel process could be seen here in regards to how change is also to also be successful in an individual who has experienced trauma.  Conscious and unconscious processes that make up each and every one of us brings perhaps a not so obvious challenge in anticipating TIA being a pragmatic process of simply increasing knowledge amongst staff.  What little change was occurring felt like a token response.  A solution for me, it seemed at the time, was to specifically work with clients through ACC Sensitive Claims.  The fact that clients have experienced sexual trauma, is an overt understanding.  This alone, it turns out, is not enough and challenges have filtered through creating an undesirable conflicting undertone.

Accident Compensation Corporation or ACC, is a government-administered organisation established in 1974, with the overall aim being to compensate those who had suffered accidental injury.  At the time, this mainly meant compensation for personal physical injury from accidents such as in the workplace, sports arena, home and motor vehicle accidents.  Consequently, this meant that the right to sue for compensatory damages was surrendered (Forster & Parkinson, 2000).   In 2002, revisions to the Injury Prevention, Rehabilitation and Compensation Act effectively meant that individuals could make a claim of mental injury as a result of sexual abuse, known as a ‘sensitive claim’.  After an initial assessment following filing an application to ACC, funding is ‘approved’ for multiple sessions of counselling by ‘approved’ ACC therapists. 

The conflict here largely seems to be around the fact that money is involved and individuals are required to go through processes in order to meet funding ‘approval’ – to be ‘approved of’ one could interpret.  In actual fact, for long-term intervention ACC has the requirement that in order to access intervention such as talking therapies, a proven DSM-V diagnosis must be provided.  Therefore, accessing funding for sexual abuse is ‘conditional’.  It assumes that one would have a DSM-V diagnosis, if they were requiring intervention as the result of sexual abuse – not exactly what I would see as fitting with the principles of TIA (ie. transparency, empowerment, collaboration). Forster & Parkinson (2000:186) state that by “insisting on proof of psychological injury, understood in conventional terms, is that some victims show no demonstrable long-term effects at all” – which statistically speaking alone (Ministry of Justice, 2015), is entirely likely. 

The conditional relationship with ACC is reminding of attachment theory and the adverse histories of most clients who present to ACC Sensitive claims.  The risk here is the provocation of early relational schema’s or working models with attachment figures and the processes of being ‘approved’ by ACC. The decision to approve funding solely lies at the discretion of ACC. This may be best described as a “power-over” (Sweeny et al. 2016:177) relationship or ‘three-cornered contract’ framework (English, 1975) in order to access therapeutic professions. Again, this may and can actually prove counterproductive to one’s therapeutic process.  It has the potential to evoke a client’s early script, replay archaic injunctions (Berne, 1961) and replicate earlier experiences for the individual where they had not been heard, believed or assisted to safety (Fallot, et al., 2011). Sweeny, et al., (2016:177) recaps –

In a trauma-informed service, it is assumed that people have experienced trauma and may consequently find it difficult to develop trusting relationships with providers and feel safe within services. Accordingly, services are structured, organised and delivered in ways that engender safety and trust and do not retraumatise.

Beyond the therapeutic bilateral model of contracting (Berne, 1966), is the model introduced by English in 1975 (Fig. 1), within the context of facilitating training workshops.

​This model effectively implies an equal working relationship between all parties – ACC, client and therapy professional for example.  From this model, further models have been developed, illustrated by an uneven triangular relationship showing greater alliance between client and therapist, while the organisation (the paying party for example such as ACC or a parent) holds a more distant yet powerful relationship.  Within the complexities of this model, I see possible ethical and moral concerns, bias, external expectations and conflicts.

Careful consideration needs to be given to sensitive claims applications in New Zealand, for Maori clients accessing therapy.  Whilst this appears to have been accounted for ‘on paper’, translation of TIA principles into the expected processes, appear to become lost.  My experience is that culturally this process has felt intrusive, with little flexibility in the time allowed for introductions, establishing connections, and removal of restrictions (tapu).  These are considered important aspects of the work for my clients.  The initial stages of ACC sensitive claims work, if not done well, transference experienced can be retraumatising and replaying intergenerational trauma.  ACC processes not aligning with kaupapa Maori values to allow fair access to intervention, is perhaps is reflected in the number of Maori clients who access counselling/therapy compared with Pakeha/European (Paton, 1999; Jansen, et al., 2008).  While Jansen, et al., (2008) found the main issue was with communication of entitlements and lack of Maori staff within the organisation, their study of Maori experiences with ACC was not solely focussed on Sensitive Claims.

Despite best attempts, aligning TIA with ACC – effectively what is seen as an insurance company – seems paradoxical at best. The ACC pathway to access and obtain trauma responsive care and funded intervention is unique and potentially invaluable.  The few studies cited above however, do not allow for generalisation of findings.  This would highlight the obvious need to evaluate and obtain viewpoints from clinicians contracted to ACC Sensitive Claims, for perceived concerns in implementing trauma informed care in practice. Such systems as the government administered organisation of ACC, could be tarnished with the very same brush that Frewin et al., (2009:44) frankly concludes with –

The identity and development of sexual abuse victims are negatively impacted by the sexual assault and by the systems, such as law enforcement and the courts, designed to support those damaged through such heinous events

Summary

Implementation of TIA is without question, a necessary evolution of how we approach mental health and wellbeing globally.  Obvious, as well as elusive resistance is emerging as attempts are made in absorbing what could be seen as a humanistic perspective to mental health care, with the more ingrained medical model approaches to mental health.  Continued enquiry of barriers, such as attitudes of clinicians and staff is needed the context of implementing TIA in health care settings.

In recognising the ongoing challenges to implementing TIA within existing mental health settings, Berliner & Kolko (2016:171) offer –

It is a desirable goal that all trauma exposed children receive a warm and caring response from knowledgeable professionals, but the most important needed change is creating systems that identify traumatized children and ensure that they get effective care.

We know that statistically New Zealand (Ministry of Justice, 2015) could do with taking a good hard look at how to approach mental health matters differently reflecting the abundance of trauma research and basic humanism.  Te Pou o te Whakaaro Nui – Trauma-Informed Care: Literature Scan (2018) is a thorough document, suggesting particular areas and common features to ensure efficient translation of their research, into mental health services in NZ.  Research continues for Maori specific approaches which will need to be assimilated nationwide as well as into the likes of ACC Sensitive Claims units.

Overall, the research demonstrates how best to respond clinically to those individuals with trauma histories.  Promisingly, this is further argued in the literature of the relevant application to multiple settings, illustrating the pervasive nature of adverse childhood experiences. These include settings that are not solely set up for mental health problems such as schools (Walkley & Cox, 2013; Overstreet & Chafouleas, 2016; Chafouleas, et al., 2016), government agencies, maternity services (Seng, et al., 2014) and A&E departments (Hall, et al., 2016). 

The principles of trauma-informed care describe the essence of being in human relationships with the other in my opinion.  The ideal is for this to become a part of the very make-up of mental health professionals amongst others, working in various settings in our communities.  The challenge perhaps lies with the simple fact that these principles – or human qualities – cannot always be ‘taught’ per se from manuals, text books or workshops. But how else do you do it?

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