Trauma informed care | Blog entry by _ RCGP Learning

Blog entry by _ RCGP Learning

Anyone in the world

Written by Dr Emma Nash

Trauma results from an event, series of events, or set of circumstances that is experienced by an individual as harmful or life threatening. Whilst unique to the individual, generally the experience of trauma can cause lasting adverse effects, limiting the ability to function and achieve mental, physical, social, emotional or spiritual well-being.¹

Most of us are aware of post-traumatic stress disorder, resulting from an acute, significant traumatic event, but less aware of complex trauma. Complex trauma is exposure to a harmful or threatening experience over a longer period, where the individual cannot escape and is particularly linked to interpersonal relationships in childhood. The concept of complex trauma specifically relates to the effect the exposure has on the person rather than the event itself. Common themes include feelings of being unsafe, trapped, powerless, ashamed, humiliated, abandoned, invalidated, rejected or unsupported. It is the effects of these emotions and experiences that cause difficulties going forwards – trauma is not about what happened, it is about how the experience affects the individual’s future.

"Trauma is not what happens to you, but what happens inside you as a result of what happens to you" (Bessel Van der Kolk²).

The effects of trauma are multi-faceted and affect the way people manage perceptions and respond to the present. These effects are greatest in childhood trauma:

Neurological: changes to brain structure and altered neurodevelopment.
Biological: alterations to cortisol levels and the immune response.
Social: interpersonal development is affected, with issues around trust and security.
Psychological: impact on mood, anxiety, expression and regulation of distress.

Whilst trauma can occur at any age, childhood trauma is particularly important because of the impact of poor attachment on brain development and the development of resilience. A child develops a sense of safety through reliability. Unreliable, inappropriate or absent responses to need leads to altered neurodevelopment and an increased stress response. The consequence is negative for executive function: working memory (attention), inhibitory control (filtering thoughts/information to resist temptation/distraction and pause before action), and cognitive flexibility (apply different rules in different settings, think outside the box, problem solve).

The effects of trauma can look like other conditions – most commonly ADHD and personality disorder, but also autistic spectrum disorders, mood or anxiety disorders, and addictions.

Symptom overlap
Complex trauma	Distorted beliefs about self. Affective dysregulation. Hypervigilance/reactivity or emotional suppression. Difficulties in sustaining relationships. Suicidal ideation & behaviour. Substance abuse. Depressive/psychotic/somatic symptoms. Dissociation. Executive dysfunction.
Personality disorder	Problems in functioning aspects of self (e.g. self-worth). Interpersonal dysfunction: developing & maintaining relationships. Maladaptive cognition, emotional experience, emotional expression, behaviour. Disproportionate negative emotions. Social/emotional detachment. Dissociative symptoms in high affective arousal.
ADHD	Impulsivity. Executive dysfunction. Difficulties with behavioural self-control. Risky behaviours. Interpersonal challenges.

Trauma-informed practice is an approach to health and care interventions which is grounded in the understanding that trauma exposure can impact an individual’s neurological, biological, psychological and social development.¹ Our experiences define our sense of self and our predictions about how people will behave towards us. Someone who has experienced trauma may have an uncertain sense of self, or struggle with interpersonal relationships as a result of inconsistent responses, lack of their needs being met, or other adverse responses to their emotional needs. As mentioned, it’s not the exact nature of the trauma that is important – at least at first – but to understand that it has happened and to recognise that it its impact. Neural network formation, and synaptic pruning (where unused connections are removed) are maximal in the first five years of life. This neuroplasticity means that the effects of trauma are easiest to reverse at this age, but harder as time goes on. By adulthood, significant investment in psychological interventions to understand the impact of trauma, and strategies to address it, is needed.

Trauma informed practice aims to create safety for patients by understanding the effects of trauma and its close links to health and behaviour. It is not about treating trauma – that is not the role of general practice – but about considering it. Applying a trauma-informed ‘lens’ can help reframe some of what you see, for example, ‘emotionally unstable’ may represent a heightened alert state, and ‘attention seeking’ may actually be ‘attachment needing’. Instead of asking ‘what is wrong with you?’, we should ask ‘what happened to you?’. It is important that we ask without re-traumatising, so don’t ask about details, you only need to know that something happened which was distressing and affected the way the patient sees themselves and their relationships with others. Applying a trauma-informed lens to patient behaviour can improve interpretation of underlying needs and emotions. The needs of an individual result in emotions, which manifest through behaviours. By applying a trauma-informed lens, the interpretation changes.

Behaviour	à	Meaning
Not engaging		Fearful
Self-harm		Ashamed
Attention-seeking		Connection-needing
Relationship issues		Let down by trusted people
Impulsivity		Hyper-reactive
Emotionally volatile		Hypervigilant
Emptiness		‘Freeze’ response
Aggression		Self-defence
Dissociation		Coping strategies
Poor concentration		Overwhelmed
Substance misuse		Seeking feeling

Governmental guidance identifies six components to trauma-informed care^1,3; fundamentally it is a thought process and attitude change. Try to have professional curiosity about the patient’s past and use that understanding to reframe their behaviour.

The key elements are:

Safety: the clinician needs to create emotional and physical safety, enable people to ask for what they need, avoid re-traumatisation (e.g. invalidation) and consider the impact of their own actions.
Trust: explain what you are doing and why, be reliable, set expectations and be transparent, make the person feel they are being listened to.
Choice: share decision making and offer choice when available, recognise that they may feel a lack of control, and validate their concerns.
Collaboration: utilise peer support, ask what they need, direct to appropriate support, and empower them where possible.
Empowerment: validate their fears, concerns and opinions, listen to their wants and needs, support them to take action themselves, and recognise low self-worth.
Cultural consideration: have self-awareness of cultural issues, bring cultural awareness and enquiries, and recognise the healing value of cultural connections.

There are multiple models for trauma recovery. Our role is in promoting safety and stability. This helps patients develop skills for managing distress and emotions, gives them control of their body and environment, encourages self-care and helps develop coping strategies.

Although there are no national guidelines published on best practice in managing complex trauma, trauma-focused cognitive behavioural therapy and trauma-focused eye movement desensitisation and reprocessing (EMDR) are most commonly used. Grounding techniques are a useful strategy to help manage distress. Treating comorbid mental health conditions and substance misuse in line with best practice also needs to take place – complex trauma should not be a barrier to accessing other help.

Key messages for general practice: