Some people may find the content of this post triggering, please only read in a safe place.
Late one evening Bill is driving home from work and is tragically involved in a serious head-on collision. Bill’s car is driven into by a van and Bill suffers with several broken bones and damaged tendons. Unfortunately for Bill, the bones he has broken are not very well understood by medics and there is no agreed treatment for them. Bill is very distressed by what happened to him and doesn’t allow anyone to talk with him about it. Eventually his broken bones get so bad he can’t walk. Bill’s wife calls an ambulance and Bill is taken to hospital where it is confirmed he is paralysed, but the cause is not investigated. Instead the medical team look to find a nursing home for Bill to move to as there is no hope of him recovering. Bill’s original untreated injury continues to cause him intense pain, but he doesn’t talk about it and no one asks.
Luckily, no one in the UK would ever experience Bill’s horror story. In the UK Bill would be looked after by paramedics who would know how best to keep Bill’s injuries stable, the local hospital would be made aware through the red trauma phone that he was coming to them and a trained team would greet him at the hospital, check his injuries and provide treatment to prevent permanent damage. If, however, Bill had been involved in something which was psychologically traumatising, such as sexual assault or abuse, his experience wouldn’t be too different from the story outlined.
There doesn’t exist a universally agreed definition of psychological trauma in the UK, however, it can roughly be described as the impact of an event(s) 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. An example of psychological trauma could be witnessing someone being murdered or sexually assaulted, being so overwhelmed by the horrible emotions you feel in response and therefore repressing the experience and memory of it.
Psychological trauma is potentially very common. In the USA it is estimated between 3.5 – 10 million children a year witness abuse of their mother and half of them are abused themselves. Not everyone who experiences something traumatic will experience psychological trauma, just as not everyone who experiences a car crash will suffer a fractured neck of femur. The difference between physical and psychological health in this case, however, is that your body will be protected, checked and treated as a universal priority. The same cannot be said for your mind.
I don’t want to argue psychological trauma into a medical condition. It isn’t. It’s a very logical and helpful way of your brain protecting you from suffering. I do, however, think we need a much better national understanding of psychological trauma, how it affects us, how to help people recover and how to not make it worse. Unfortunately, without this agreed understanding, we end up only dealing with the ingrained consequences of trauma after years of suffering. Most trauma survivors will name feelings of shame, guilt and often an inability to remember what has happened thanks to their brain protecting them from the memory. This results in very few survivors talking about and seeking help with their experience early. Such traumatic experiences cannot just disappear though, and the resulting impact presents itself in different ways. People express feelings of anger, inability to trust others, low self-esteem, issues with substances, stress, difficulty sleeping and many other feelings. Because of these emotions and associated behaviours people are often diagnosed with mental health issues such as PTSD, Depression, Emotionally Unstable Personality Disorder, and Dissociative disorders. There is also a growing evidence base of a link between other diagnosable illnesses such as psychosis. Equally, based on no evidence other than the people I have met in my career providing mental health services, I also believe there may be a link between psychological trauma and mania, bi-polar, challenging behaviour, OCD and medically unexplained symptoms.
There is a debate to be had about how useful or harmful it is to diagnose the impact of trauma and a wealth of discussion, literature and passionate speaking on the subject. Wherever you stand on the usefulness-or-not of diagnosis debate, we need to question why don’t we react to psychological trauma in the same way we do physical trauma? Before anyone argues a person is more likely to die from physical trauma, I’ll remind us that more people die from suicide than road traffic accidents. Colleagues in some part of the world argue that psychological trauma needs to be treated as a public health issue, and I would agree. Aside from the obvious moral argument, the impact on our health system (and beyond) is potentially huge, so a harm-minimisation approach would stack up financially. American research tells us between 20-50% of abused children will have a disability as a result. It also tells us between 81-93% of patients using psychiatric hospitals have experienced abuse and 84% of children in juvenile detention report childhood trauma.
As we don’t have an evidence based, national approach to trauma a lot of people end up in health, social, housing, addiction and criminal systems instead. Unfortunately, by the very nature of a lot of these services they end up making things much, much worse. My specific interest in this case is our mental health system, which, despite the best efforts of staff, ends up re-traumatising people and preventing healing taking place. The first issue we have is the lack of nationally agreed best practice regarding psychological trauma. We have guidelines for treating the illnesses we diagnose people with as a result of trauma, but no guidance on what to do and what not to do in response to someone who is psychologically traumatised. We also have limited access to those trauma informed interventions which have been approved to ‘treat’ trauma such as EMDR (Eye Movement Desensitisation and Reprocessing).
However, most harmful of all is the structure of our current mental health system which is fragmented, not trauma informed/focused and often responds to people’s distress by taking control away from them. In mental healthcare we sometimes take people’s control away from them to keep them physically safe. However, when someone has suffered psychological trauma such as sexual abuse they have had control taken away from them in the most horrific way and hence, will have a tricky relationship with control. Understandably then, being forced into hospital, denied leave, forced to take medication, restrained, forcibly injected with tranquilizers or locked in seclusion could be re-traumatising and damaging for someone who has had control taken away from them in such a harmful way.
All of us who have worked in acute mental health care have seen what happens when someone with such experiences is forced into hospital. They feel out of control as their usual coping mechanisms have been removed so they self-harm to feel in control. We, as dutiful healthcare staff can’t let that happen, so we remove all sharp objects and things escalate. The person tries to kill them self, we have to restrain them to stop them doing so, causing them to relive the time they were raped. The person becomes so distressed they end up in seclusion in rip-proof clothing awaiting an expensive ‘specialist bed’ in a private hospital. As illustrated by this example, probably taking place across the country as I write, this approach doesn’t work. It is beyond horrifying for the person and pretty traumatising for staff too. Our current systems force this never-ending cycle, but they don’t have to. Our colleagues in housing and substance use sectors work in a trauma informed way as do our international mental health colleagues. Research into what is called trauma-informed environments tell us they need to be:
• safe (psychologically, socially and physically)
• trusting & mutual
• control, coercion and violence limited
By being trauma informed services shift mindsets from asking ‘what’s wrong with you’ to ‘what’s happened to you’ and view behaviour which challenges others in the context of the function it serves the victim. Studies into trauma informed environments find them to be more effective and financially viable than non-trauma informed services. Those who have worked in therapeutic communities know firsthand the improved experiences and outcomes for all involved. A trauma informed system will deliver better results and cost less – and not just for mental health services. As we continue to hear in the news, media and popular TV shows such as Ambulance, people with these needs often end up picked up by the police in such distress having tried to harm themselves and being taken to A&E by an ambulance. This can happen so often for some people the system has unfairly named them ‘frequent flyers’ or ‘revolving door patients’, failing to comprehend that the reason the person keeps coming back is that the system has failed them!
So, UK, I think its time for a trauma informed revolution. We know there are ways to structure our services, to provide better treatment options and to increase understanding that will enable better outcomes for people and the system. We know our staff want this, our system needs it and the people who have suffered deserve it.
Who’s with me?