Trauma The Hidden Wound and the Importance of Trauma Informed Care in the NHS

*’Transforming Trauma Discovering wholeness and healing after trauma ‘2019  is an excellent new book by Dr James Gordon.

What exactly is trauma, do you always know if you’ve been traumatised, does it always have hallmarks, what are its consequences?  And do healthcare professionals, nurses, hospital doctors and GPs  – across the board – know how to recognise someone who may be suffering from trauma, how best to help them and to avoid retraumatising  them?

It was probably no surprise to most people when psychological trauma hit the news in the summer last year.  In the wake of the terrifying Grenfell Tower fire in London on the 14th June 2017,  the Guardian reported 2 August 2017 that thousands of people  may suffer psychological trauma as a result e.g. adults and children who survived, families of those who survived and those who didn’t, passers-by, fire crews, helpers and so on. People were complaining of problems like insomnia, difficulties eating, anxiety, depression, feeling disconnected  and PTSD (post traumatic stress disorder –  distressing flashbacks).

Most of us I think can understand trauma occurring as a result of this horrifying event but what is less well known is that you can become traumatised from less obvious experiences, that trauma is much more widespread than we think, and underpins many  mental and physical health problems blighting lives. There is increasing recognition of this and big changes are underway in how the NHS helps people recover from trauma.

Shortly after the fire I went to an excellent conference held by the Queen’s Nursing Institute ‘Managing Psychological Trauma in Healthcare’ 5th July 2017

I found the presentation ‘Bringing A Trauma Informed Care Approach (TIC) into the NHS’  by Jonathan Ogram a nurse expert in mental health and trauma who works for the Tees Esk and Wear Valleys  (TEWV) NHS  Foundation Trust, a large mental health provider, illuminating and full of hope.

Trauma,  when you experience something as threatening and dangerous and feel overwhelmed by it can become embedded. The distressing memories are not properly laid to rest, keep resurfacing either obviously so or below  conscious awareness.

And that can result in physiological  changes in the brain. The amygdala the fear centre in the older emotional part of the brain becomes exquisitely sensitive  to any possible sign of danger and may increase in size; meanwhile the hippocampus which helps store memories  may shrink in size and blood flow to the left side of the prefrontal cortex (often called the top brain) may reduce affecting language whilst blood flow to the right side increases which may make you feel more moody, sadder and angrier.

The upshot of all this  is that you’re likely to feel on red alert all the time which is exhausting, you can’t think straight and  feel you can’t cope with life. And you can be affected not only mentally but also physically, emotionally and socially. It’s like a hidden wound says Jonathan which can wreak havoc in people’s  lives leading to e.g. domestic violence.

Whether you become traumatised by something depends not so much on the event itself  but critically how you experience it which in turn links to various factors e.g. your coping resources what’s happened to you in life, how genetically resilient you are and when the event occurred – a toddler may for instance be distraught if they’re left alone in a cold room whereas a teenager may just be mildly annoyed.

Seen this way the journalist Deborah Orr’s recent account in the Guardian  23 September 2017 makes sense. She says she was diagnosed with complex post traumatic stress disorder last year but the original trauma she’d suffered was years ago. “It took me 50 years to realise that being duped and robbed of my gold christening bracelet the first time I ever left my home alone, at the age of three was traumatic”. And you can become retraumatised if things in the present stir up memories of the original trauma.

Trauma informed Care (TIC)  is being rolled out across the whole of the TEWV Trust,  probably the first to do so,   by  consultant clinical psychologist Angela Kennedy after a successful pilot in the Trust showed its benefits (she was a co-author of a paper published in 2016 ‘Trauma-informed mental healthcare in the UK; what is it and how can we further its development’ ).

It’s a recognition of the fact that trauma can affect everyone including staff,  is often hidden from view and that the majority of people who seek help from mental health services have been traumatised, there’s also a strong association between trauma and childhood abuse and poverty. Angela  says current NHS practice which sometimes involves coercion, control and forcible medication can retraumatise people and that has to change. Angela also points out that trauma can affect not just the mind but the body too and may underpin health problems like obesity, heart disease, alcohol misuse and diabetes. A feature I wrote in 2014 for Nursing Standard ‘Easing ICU trauma’ looked at the trauma suffered by some patients after going through intensive care. Hospitals are also very stressful places generally for some people and may trigger retraumatisation in some people. And in the GP surgery,  trauma may be the root cause of a patient’s problem  manifesting itself in perhaps psychological and/or physical symptoms.  So staff working in all healthcare settings not just mental health ones need to be better informed about trauma and to understand they too can become traumatised in certain circumstances.

TIC principles are based first and foremost on support which involves helping people feel safe physically and emotionally. They can then start to take control of their lives, says Jonathan who is helping to implement TIC. You don’t start by asking about symptoms, about what’s wrong with someone. Instead you give them space and time so they can tell you their story so you better understand what lies behind the symptoms and what has happened to them. And you need to make sure you don’t retraumatise  by bringing up something which can trigger the original trauma.  Alongside this various techniques like breathing exercises are offered to help people feel more in control.

When the time is right trauma  treatments like EMDR (eye movement desensitisation and reprocessing) a NICE approved treatment can be offered  where a therapist  gets you to move your eyes quickly side to side. These mimic the eye movements in rapid eye movement sleep allowing distressing memories to be reprocessed and put back in the past where they belong. There’s good evidence for its effectiveness but it’s not right for everyone says Jonathan who is also an EMDR therapist. The good news is that there are various mind/body therapies (NICE also recommends trauma-focused cognitive behavioural therapy) which help you recover and move on with your life.

*Good books to read include: ‘Making Sense of Trauma How to tell  your story’ by psychologists Dr Nigel Hunt and Dr Sue McHale;  ‘The Body Keeps The Score Brain Mind and Body in the Healing of Trauma’  by psychiatrist and trauma expert Bessel Van Der Kolk; ‘Post-Traumatic Stress Disorder’ by psychologist Professor Kevin Gournay; ‘Post-Traumatic Stress Disorder  Recovery after accident and disaster’ by Professor Kevin Gournay