In recent years, trauma-informed ways of working have been increasingly advocated to lessen the negative impact of childhood adversities and improve mental health outcomes. There has also been an increase in policies citing trauma-informed approaches to improve the quality of CYPMHS services (OHID 2022, SAMHSA 2014).
However, there is less agreement about the most effective way to put trauma-informed principles into practice, which leads to variances and inconsistencies across children’s social care settings (Asmussen et al., 2022). Currently, there is no single model of trauma-informed care that exists within CYPMHS in England, but some leading care providers are exploring the benefits of using a trauma lens to inform CYPMHS care (being sensitive to the impact of trauma on a young person’s emotions and behaviour).
In this CYPMHS EveryExpert article, we talk with Elise Stephen, Consultant Clinical Psychologist and Deputy Therapies Lead at Potters Bar Clinic in Hertfordshire. As part of Elysium Healthcare’s CYPMHS provision, Potters Bar Clinic offers a Tier 4 low secure service for young people aged 13-18 with a wide range of mental health disorders and complex needs.
Over the past four years, Elise has been leading a number of initiatives at the service to ensure that the clinical model and systemic ways of working are informed by a trauma lens. According to Elise, comprehensive training and ongoing team-wide reflective practice play an important role in creating a trauma-sensitive culture that enables all team members, irrespective of their role or level of experience, to work therapeutically.
Elise says: “At Potters Bar, we’re aiming towards being more trauma-informed in our way of practising, and use a trauma lens to shape the CYPMHS care that we provide. We have a particular focus on systemic working, and we’re developing ways of working for the service that upskill the system around the young person to see things through a trauma lens. For example, the frontline staff team, their social worker, or their family.
“Transforming our systemic working across our services is vital in achieving positive outcomes, because it is the support systems that have the most contact with the young person. There is, of course, an important place for the specialist psychological work that I do with young people one-to-one, however, that’s only one hour of therapy a week, whereas we have inpatient staff who are doing 12-hour shifts with the young person. Therefore, how they are interacting with the young person matters more, or at least as much, as the direct clinical intervention that I might be providing using dialectical behaviour therapy (DBT) or cognitive analytic therapy (CAT).”
CYPMHS trauma lens training and induction
Ensuring that a trauma lens informs each and every aspect of care within a CYPMHS service means that all systems need to be sensitive to the impact of trauma on an individual’s journey. The frontline team is at the heart of those systems, and Elise explains how she has introduced a new induction and ongoing reflective practice that is designed to support the team and equip them to retain empathy in the face of very trying circumstances.
Elise says, “It is important that new team members understand our approach and clinical model right from the outset. So we have introduced a comprehensive induction that helps them conduct their work, in whatever role that may be, through a trauma-sensitive lens. We offer training around trauma-informed formulations and DBT skills training.
“The ‘Working Therapeutically’ training has been developed by the psychology department at Potters Bar Clinic. This training is informed by Cognitive Analytic Therapy (CAT) and Dialectical Behaviour Therapy (DBT) principles. The training educates staff on the principles of trauma-informed care, including understanding formulation, boundaries, team splitting, and how to engage therapeutically with patients. There is a focus on staff skills development related to particular presenting problems such as self-harm, aggression and disordered eating. There is also an educational component regarding transgender and sexuality considerations.
“This might be the first time they have worked in a low secure setting, so much of what they encounter will be new, so it’s important to equip them with the right skills and understanding. The induction and training within it help our team retain their empathy for the young people we support and enable them to work therapeutically through a trauma lens.
“As a key staff member, HCA or nurse, you have to be aware that you’re in a position of power. This awareness then informs how we interact with the young person, so that the power dynamic is less present, and instead we work collaboratively, alongside the individual. The training also helps the team to understand the function behind those behaviours, the reason why young people might be being aggressive or engaging in self-harm.”
Reflective Practice
As with many professional settings, what is learnt on the first day of a job is not always fully retained, with learning lost over time. In order to mitigate this risk and support learning from the induction to be embedded in daily practice, the team at Potters Bar participate in regular reflective practice sessions. For Elise, it was important to offer the front-line team an opportunity to process what happens on shift and their responses to that.
Elise says: “Our reflective practice sessions are formulation-driven and sensitive to trauma histories, and it helps embed what they’ve learned in their initial training into their day-to-day practice. We run them twice a week for both day and night staff, which allows each shift pattern to come once a month.
“During this hour of reflective practice, we talk about what the team has experienced in their work and how they have responded. We look a lot at power relationships and discuss how we step out of the traditional power dynamics of an inpatient setting so that we can walk alongside someone who’s experienced trauma. Even if they are behaving in a physically or verbally aggressive way towards us, we explore how we can remain empathetic.
“Within the sessions, we discuss how we hold on to a psychologically informed view of those difficulties, which, as I explain to the team, always comes back to understanding the function of the behaviour. Having the view of what it is that the person is trying to achieve – are they trying to regain control, or do they want to feel safe?
“The reflective practice has produced a huge shift in the way the team interact with the patients, as they now have a more psychologically-minded view of the difficulties the patient experiences. They are more aware of the patient’s trauma, which informs how they work, all the while contributing to our trauma-sensitive culture here at Potters Bar.”
Hospital-wide implementation
Successfully implementing reflective practice hospital-wide was not without its obstacles. As Elise explains, a significant hurdle to overcome was ensuring the sessions were accessible across different teams and competing rotas.
Elise says: “It can be challenging to implement reflective practice team-wide within an inpatient setting because it is difficult to get people released from their duties on the ward. As a solution, the Hospital Director agreed to rota an extra hour at handover to allow time for the session. This meant the night shift would stay an extra hour and cover an hour of the day shift, and vice versa. So before people got their handover, they worked as a team with the psychologist for an hour.”
It was also vital to establish trust within the group so that people feel safe to share their personal feelings and experiences. Trust is often hard earned, so Elise describes how she was able to ensure the group felt comfortable together in a relatively short space of time.
Elise says: “When I first started reflective practice, some of the team were reluctant to speak. In order for reflective practice to be effective, there also needs to be sensitivity around what the team members are experiencing in their work. If you are working with patients who are high risk, it can affect you. For example, if patients attempt to harm themselves or other people, and you’re seeing this on an ongoing basis, it can be a distressing environment to work within.
“So I prioritised supporting the team to feel safe by showing understanding and empathy towards them. Working 12-hour shifts with acute patients is very challenging, and for reflective practice to be successful, the demands and the impact of the job need to be acknowledged. I would start each session by recognising the reality of their work and making sure they had the support they needed. Gradually, as the sessions progressed, those who hadn’t felt comfortable talking previously opened up and were able to discuss their work.”
Systemic benefits of reflective practice
The Potters Bar team have seen multiple benefits of reflective practice for both the young people they support and the staff team, but perhaps one of the most surprising is improvements to staff retention.
Elise says: “Although I don’t have data to hand that proves this, I can say from my personal observations that reflective practice and the additional training we have put in place have improved staff continuity. We have more consistency in our staffing and less reliance on non-permanent staff. Where we do use agency staff, it tends to be the same people, meaning we have continuity within our reflective practice groups, and we can maintain our working culture and trauma-sensitive clinical model. It is also likely that these interventions have worked to reduce any restrictive practices, as the team work more therapeutically with young people and the systems around them.
“We now want to build upon the success that we have achieved at Potters Bar and try to embed these trauma-informed practices at our other CYPMHS services.”
References
Asmussen, K., Masterman, T., McBride, T., & Molloy, D. (2022). Trauma-Informed Care. Understanding the Use of Trauma-Informed Approaches Within Children’s Social Care. London: Early Intervention Foundation.
Substance Abuse and Mental Health Services Administration. SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. HHS Publication No. (SMA) 14-4884. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014.
Office for Health Improvement and Disparities. (2022). Working definition of trauma-informed practice. UK Government.