# data[].attributes.headline
Team as a secure base model for supervisors 

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Team as a secure base model for supervisors 

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Do Do social work podcast with Dr Langhoff - trauma informed practice

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Do Do social work podcast with Dr Langhoff - trauma informed practice

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Come What May....Life lessons for coping with crisis Lucy Easthope

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Come What May....Life lessons for coping with crisis Lucy Easthope

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Professor Lucy Easthope: Life-Changing Lessons For Coping With Crisis

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Healing from Historical Trauma: Understanding Trauma Part 2

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Research by University of Bristol and COECT on carer compassion fatigue

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This resource from Beacon House explains secondary trauma very well!

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Dr Daniel Siegal Burning out to Burning Bright

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Dr Daniel Siegal Burning out to Burning Bright

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Dr. Daniel Siegel | Burning Out to Burning Bright

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Amazing website, resources, services, books and podcasts

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Trauma Informed Working Staffordshire violence reduction

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Trauma Informed Working Staffordshire violence reduction

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Trauma Informed Stoke-on-Trent and Staffordshire - Violence Reduction Alliance

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If you’re involved in, or affected by violence, it’s never too late to get help. Find help and support available to you.

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Adoption Triad (2019, October). Attachment and Developmental Stages Throughout Childhood. Child Welfare.

Andersen, T. E., Ravn, S. L., Manniche, C., & O'Neill, S. (2018). The impact of attachment insecurity on pain and pain behaviors in experimental pain. Journal of Psychosomatic Research, 111, 127-132.

Andriopoulou, P. (2021). Healing attachment trauma in adult psychotherapy: The role of limited reparenting. European Journal of Psychotherapy & Counselling, 23(4), 468-482.

Cassioli, E., Rossi, E., Vizzotto, C., Malinconi, V., Vignozzi, L., Ricca, V., & Castellini, G. (2022). Avoidant Attachment Style Moderates the Recovery of Healthy Sexuality in Women With Anorexia Nervosa Treated With Enhanced Cognitive Behavior Therapy (CBT-E): A 2-Year Follow-Up Study. The journal of sexual medicine, 19(2), 347-355.

Collins, N. L., & Feeney, B. C. (2004). Working Models of Attachment Shape Perceptions of Social Support: Evidence From Experimental and Observational Studies. Journal of Personality and Social Psychology, 87(3), 363-383.

Dagnino, P., Pérez, C., Gómez, A., Gloger, S., & Krause, M. (2017). Depression and Attachment: How do Personality Styles and Social Support Influence This Relation?. Research in psychotherapy (Milano), 20(1), 237.

Fearon, P., Bakermans-Kranenburg, M. J., Van IJzendoorn, M., Lapsley, A., & Roisman, G. I. (2010). The Significance of Insecure attachment and Disorganization in the Development of Children's Externalizing Behavior: A Meta-Analytic Study. Child Development, 81(2), 435-456.

Lahousen, T., Unterrainer, H. F., & Kapfhammer, H. P. (2019). Psychobiology of Attachment and Trauma-Some General Remarks From a Clinical Perspective. Frontiers in psychiatry, 10, 914.

Malekpour, M. (2007). Effects of attachment on early and later development. British Journal of Developmental Disabilities, 53(105,Pt2), 81-95.

Rees C. (2007). Childhood attachment. The British journal of general practice: the journal of the Royal College of General Practitioners, 57(544), 920-922.

Romeo, A., Tesio, V., Castelnuovo, G., & Castelli, L. (2017). Attachment Style and Chronic Pain: Toward an Interpersonal Model of Pain. Frontiers in psychology, 8, 284.

van Ijzendoorn, M. H., Schuengel, C., & Bakermans-Kranenburg, M. J. (1999). Disorganized attachment in early childhood: meta-analysis of precursors, concomitants, and sequelae. Development and psychopathology, 11(2), 225-249.

# data[].attributes.attachment_link.title
Attachment Trauma: What is it? - Attachment Project

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What are the signs and how do we heal from attachment trauma? Read the article now to discover the ins and outs of attachment trauma.

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Introduction

What is attachment theory and why is it important?

Attachment is a clinical term used to describe "a lasting psychological connectedness between human beings" (Bowlby, 1997). In particular, attachment theory highlights the importance of a child's emotional bond with their primary caregivers. Disruption to or loss of this bond can affect a child emotionally and psychologically into adulthood, and have an impact on their future relationships.

Only specially trained and qualified professionals should assess a child's attachment style. However, it's important for all adults working with children to understand what attachment is and know how to help parents and carers become attuned to their child's needs. You might do this by working with them directly, or by signposting families to other appropriate services. In the long term, this can help improve wellbeing and provide positive outcomes for both the child and their caregivers.

Understanding attachment in the early years

Children can form attachments with more than one caregiver, but the bond with the people who have provided close care from early infancy is the most important and enduring (Bowlby, 1997).

It's important that parents and carers are attuned and responsive to their baby's needs and are able to provide appropriate care. This includes recognising if their baby is hungry, feeling unwell or in need of closeness and affection (Howe, 2011).

Forming an attachment is something that develops over time for a child, but parents and carers can start to form an emotional bond with their child before they are born. Sometimes a parent or carer may have difficulty forming this bond, for example if they are experiencing mental health issues or don't have an effective support network.

On this page, you'll find information on:

why attachment is important

how children develop attachment

attachment issues, insecure and secure attachment and behaviours to look out for

how trauma can affect attachment

how you can support parents and carers to develop a bond with their child.

Need specific information?

Our information specialists are here to help you find research, guidance and best practice.

References

Bowlby, John (1997) Attachment and loss. Volume 1: attachment. London: Pimlico.
Bowlby, John (1997) Attachment and loss. Volume 1: attachment. London: Pimlico.
Howe, David (2011) Attachment across the lifecourse: a brief introduction. Basingstoke: Palgrave Macmillan.

Stages of attachment

Stages of attachment

The first two years of a child's life are the most critical for forming attachments (Prior and Glaser, 2006).

During this period, children develop an 'internal working model' that shapes the way they view relationships and operate socially. This can affect their sense of trust in others, self-worth and their confidence interacting with others (Bowlby, 1997).

When are attachments formed?

Attachments are formed in different ways during the phases of a child's development.

Antenatal (before birth)

During the antenatal period, parents and carers can form a bond with their child. Any bonds formed before birth can have a positive impact on the relationship between babies and their caregivers once the child is born (Condon and Corkindale, 1997).

Birth until 6 weeks

This is sometimes referred to as the pre-attachment phase because the baby doesn't appear to show an attachment to any specific caregiver. However, parents and carers who provide a nurturing environment and are responsive to their babies needs can lay the foundation for secure attachments to form (Bowlby, 1997).

6 weeks until 6-8 months

During this stage of their development, a baby might start to show a preference for their primary and secondary caregivers (often the mother and father).

6-8 months until 18 months-2 years

During this period a child begins to show a strong attachment to their primary caregivers. Babies start to develop separation anxiety during this phase and can become upset when their caregiver leaves, even for short periods (Bowlby, 1997).

18 months - 2 years onwards

At this point children are likely to become less dependent on their primary caregiver, particularly if they feel secure and confident the caregiver will return and be responsive in times of need (Bowlby, 1997).

References

Prior, V. and Glaser, D. (2006) Understanding attachment and attachment disorders: theory, evidence and practice. London: Jessica Kingsley. Condon, J. T. and Corkindale, C. (1997)
Bowlby, John (1997) Attachment and loss. Volume 1: attachment. London: Pimlico.

The correlates of antenatal attachment in pregnant women. British Journal of Medical Psychology. Cambridge University Press, 70 (4): 359-372. Bowlby, John (1997) Attachment and loss. Volume 1: attachment. London: Pimlico.
Bowlby, John (1997) Attachment and loss. Volume 1: attachment. London: Pimlico.
Bowlby, John (1997) Attachment and loss. Volume 1: attachment. London: Pimlico.

Types of attachment

Types of attachment

A child's need for attachment is part of the process of seeking safety and security from their caregiver.

What does secure attachment look like?

In secure caregiver-child relationships, the caregiver is usually sensitive and tuned in to the child's needs. They are able to provide care that is predictably loving, responsive and consistent.

Young children who have formed a secure attachment to their caregiver may display the following patterns of behaviour during times of stress or exploration:

proximity maintenance - wanting to be near their primary caregiver

safe haven - returning to their primary caregiver for comfort and safety if they feel afraid or threatened

secure base - treating their primary caregiver as a base of security from which they can explore the surrounding environment. The child feels safe in the knowledge that they can return to their secure base when needed

separation distress - experiencing anxiety in the absence of their primary caregiver. They are upset when their caregiver leaves, but happy to see them and easily comforted when they return

Benefits of secure attachment

When caregivers react sensitively to ease their child's distress and help them regulate their emotions, it has a positive impact on the child's neurological, physiological and psychosocial development (Howe, 2011).

Children with secure attachments are more likely to develop emotional intelligence, good social skills and robust mental health (Howe, 2011).

Effects of insecure attachment

Not receiving comfort and security in the early years can have a negative effect on children's neurological, psychological, emotional and physical development and functioning (Newman, 2015).

Babies and young children who have attachment issues may be more likely to develop behavioural problems such as attention deficit hyperactivity disorder (ADHD) or conduct disorder (Fearon et al, 2010).

Children who have attachment issues can have difficulty forming healthy relationships when they grow up. This may be because their experiences have taught them to believe that other people are unreliable or untrustworthy (Bowlby, 1997).

Adults with attachment issues are at a higher risk of entering into volatile relationships and having poor parenting skills, behavioural difficulties and mental health problems (Howe, 2011).
> Find out more about how trauma affects child brain development
Further reading

Take a look at our reading list on child attachment.
> View the reading list on the NSPCC Library catalogue

Attachment issues

Attachment issues

Factors affecting attachment

Some circumstances can make it more challenging for a child and their caregivers to form a pattern of secure attachment. These may include:

abuse, maltreatment and trauma experienced by the parent or child

parental mental health difficulties

parental substance misuse

the child having multiple care placements

parents being separated from their baby just after birth, for example if the baby is receiving neonatal care

stress such as having a low income, being a single parent, or being a young parent

bereavement or loss of another caregiver that a child had an attachment with

Signs that a child may have attachment issues

Children's behaviour can be influenced by a wide range of circumstances and emotions.

Indicators that a baby or toddler might not have a secure attachment with their caregiver will emerge as a pattern of behaviour over time, particularly during moments of stress or exploration. This pattern might include:

being fearful or avoidant of a parent or carer

becoming extremely distressed when their carer leaves them, even for a short amount of time

rejecting their caregiver's efforts to calm, soothe, and connect with them

not seeming to notice or care when their caregiver leaves the room or when they return

being passive or non-responsive to their carer

seeming to be depressed or angry

not being interested in playing with toys or exploring their environment

As children with attachment issues get older, these behaviour patterns might evolve. As well as being evident during times of stress, some behaviours may start to become obvious at other times. These may include the child:

finding it difficult to ask for help

struggling to form positive relationships with adults and peers

struggling to concentrate

struggling to calm themselves down

both demanding and rejecting attention or support at the same time

becoming quickly or disproportionately angry or upset, at times with no clear triggers

appearing withdrawn or disengaged from activities

daydreaming, being hyperactive or constantly fidgeting or moving

(Mentally Healthy Schools, 2020).

If you think a child may have attachment issues, you should refer them to a suitably trained health and social care professional for a full assessment. You should follow your organisation's procedures to make a health and social care referral, or contact your local authority children's social care services.

References

Bowlby, John (1989) The making and breaking of affectional bonds. London: Routledge. Mentally Healthy Schools (2020)
Howe, David (2011) Attachment across the lifecourse: a brief introduction. Basingstoke: Palgrave Macmillan.
Attachment and child development. [Accessed 09/11/2020].

Trauma and attachment

Trauma and attachment

The signs of attachment issues can be similar to indicators that a child is experiencing other challenges, such as:

This means it's important to consider everything that's going on in a child's life and make sure they and their family are provided with appropriate support.

Think about all your previous experiences with the child and their caregivers, to help you build a clear picture of their relationships and recognise any concerning patterns of behaviour.

The impact of trauma and attachment

Children who have experienced abuse, neglect and trauma might develop coping strategies that can make it more complicated to recognise attachment issues.

For example, one sign of secure attachment is that children see their caregiver as a secure base to explore from. But children who have experienced neglect, for example, might display independent behaviour in order to protect themselves from the emotional pain of not having their needs met (Marvin et al, 2002).

It is also possible for a child to develop an attachment to someone who is maltreating them (Blizard & Bluhm, 1994).

As well as affecting attachment, experiencing trauma can have an impact on a child's brain development. Children might need extra support to help strengthen the architecture of their brain.
> Find out more about how trauma affects child brain development
What to do if you're worried that a child is experiencing or at risk of abuse or neglect
If a child is in immediate danger, call the police on 999.
If you're worried about a child but they are not in immediate danger, you should share your concerns.

Follow your organisation's child protection procedures without delay. These should provide clear guidelines on the steps you need to take if a child discloses abuse. They will state who in your organisation has responsibility for safeguarding or child protection and who you should report your concerns to.

Contact your local child protection services. Their contact details can be found on the website for the local authority the child lives in.

Contact the police. They will assess the situation and take the appropriate action to protect the child.

Contact the NSPCC Helpline on 0808 800 5000 or by emailing help@nspcc.org.uk. Our child protection specialists will talk through your concerns with you, give you expert advice and take action to protect the child as appropriate. This may include making a referral to the local authority.

> Find out more about recognising and responding to abuse
If your organisation doesn't have a clear safeguarding procedure or you're concerned about how child protection issues are being handled in your own, or another, organisation, contact the Whistleblowing Advice Line to discuss your concerns.
> Find out about the Whistleblowing Advice Line on the NSPCC website
When you're not sure

The NSPCC Helpline can help when you're not sure if a situation needs a safeguarding response. Our child protection specialists are here to support you whether you're seeking advice, sharing concerns about a child, or looking for reassurance.

Whatever the need, reason or feeling, you can contact the NSPCC Helpline on 0808 800 5000 or by emailing help@nspcc.org.uk

Our trained professionals will talk through your concerns with you. Depending on what you share, our experts will talk you through which local services can help, advise you on next steps, or make referrals to children's services and the police.
> Find out more about how the NSPCC Helpline can support you

Supporting children and families

Supporting children and families

Building positive relationships

It's important for anyone who works with children and families to support parents and carers in building positive relationships with their child. Having positive interaction and play with caregivers can help a child's brain to develop healthily.
> See our early years resources which you can share with parents and caregivers
Video feedback programmes can also be used by specially trained social care professionals to help caregivers improve their interactions with their child. This involves caregivers being filmed when they are interacting with their child and then watching the recording with a trained practitioner, who gives them feedback and helps them build on their strengths.

Support for parents and carers

If parents are struggling with their own issues, it may make it harder for them to bond with their child and provide consistant and responsive care. They may have:

experienced abuse of trauma themselves

drug and/or alcohol dependencies

mental health issues.

> Find out more about parental mental health > Learn more about parental substance misuse
Services for children and families

The NSPCC has many services that children and families can be referred to, from supporting parents and carers in taking care of their children to preventing sexual abuse and overcoming abuse.

Our services might be suitable for children and families you are working with:

Pregnancy in Mind helps parents who are at risk of or experiencing mild to moderate anxiety and depression during pregnancy. The service helps build parents' capacity to provide sensitive, responsive care to their babies and keep these skills developed postnatally and as their children develop
Browse for more services
Further reading

Take a look at our reading list about child attachment interventions, support and treatment.
> View the list on the NSPCC Library catalogue
Supporting children's mental health

Children with attachment issues may have problems expressing or controlling their emotions and forming positive relationships, which might affect their mental health.

It's important to make sure children and young people have access to mental health support.
> Find out more about child mental health > See the NSPCC's advice for parents and carers on how to support their child's mental health
Childline

If a child or young person needs confidential help and advice you can always direct them to Childline. Calls to 0800 1111 are free and children can also contact Childline online. Children under the age of 12 can be directed to the Childline Kids website.

We also have a series of posters and wallet cards you can download for free. These can be printed and displayed in your setting to encourage children to contact Childline if they need to talk.

Introduction

What is attachment theory and why is it important?

Attachment is a clinical term used to describe "a lasting psychological connectedness between human beings" (Bowlby, 1997). In particular, attachment theory highlights the importance of a child's emotional bond with their primary caregivers. Disruption to or loss of this bond can affect a child emotionally and psychologically into adulthood, and have an impact on their future relationships.

Only specially trained and qualified professionals should assess a child's attachment style. However, it's important for all adults working with children to understand what attachment is and know how to help parents and carers become attuned to their child's needs. You might do this by working with them directly, or by signposting families to other appropriate services. In the long term, this can help improve wellbeing and provide positive outcomes for both the child and their caregivers.

Understanding attachment in the early years

Children can form attachments with more than one caregiver, but the bond with the people who have provided close care from early infancy is the most important and enduring (Bowlby, 1997).

It's important that parents and carers are attuned and responsive to their baby's needs and are able to provide appropriate care. This includes recognising if their baby is hungry, feeling unwell or in need of closeness and affection (Howe, 2011).

Forming an attachment is something that develops over time for a child, but parents and carers can start to form an emotional bond with their child before they are born. Sometimes a parent or carer may have difficulty forming this bond, for example if they are experiencing mental health issues or don't have an effective support network.

On this page, you'll find information on:

why attachment is important

how children develop attachment

attachment issues, insecure and secure attachment and behaviours to look out for

how trauma can affect attachment

how you can support parents and carers to develop a bond with their child.

Need specific information?

Our information specialists are here to help you find research, guidance and best practice.

References

Bowlby, John (1997) Attachment and loss. Volume 1: attachment. London: Pimlico.
Bowlby, John (1997) Attachment and loss. Volume 1: attachment. London: Pimlico.
Howe, David (2011) Attachment across the lifecourse: a brief introduction. Basingstoke: Palgrave Macmillan.

Stages of attachment

Stages of attachment

The first two years of a child's life are the most critical for forming attachments (Prior and Glaser, 2006).

During this period, children develop an 'internal working model' that shapes the way they view relationships and operate socially. This can affect their sense of trust in others, self-worth and their confidence interacting with others (Bowlby, 1997).

When are attachments formed?

Attachments are formed in different ways during the phases of a child's development.

Antenatal (before birth)

During the antenatal period, parents and carers can form a bond with their child. Any bonds formed before birth can have a positive impact on the relationship between babies and their caregivers once the child is born (Condon and Corkindale, 1997).

Birth until 6 weeks

This is sometimes referred to as the pre-attachment phase because the baby doesn't appear to show an attachment to any specific caregiver. However, parents and carers who provide a nurturing environment and are responsive to their babies needs can lay the foundation for secure attachments to form (Bowlby, 1997).

6 weeks until 6-8 months

During this stage of their development, a baby might start to show a preference for their primary and secondary caregivers (often the mother and father).

6-8 months until 18 months-2 years

During this period a child begins to show a strong attachment to their primary caregivers. Babies start to develop separation anxiety during this phase and can become upset when their caregiver leaves, even for short periods (Bowlby, 1997).

18 months - 2 years onwards

At this point children are likely to become less dependent on their primary caregiver, particularly if they feel secure and confident the caregiver will return and be responsive in times of need (Bowlby, 1997).

References

Prior, V. and Glaser, D. (2006) Understanding attachment and attachment disorders: theory, evidence and practice. London: Jessica Kingsley. Condon, J. T. and Corkindale, C. (1997)
Bowlby, John (1997) Attachment and loss. Volume 1: attachment. London: Pimlico.

The correlates of antenatal attachment in pregnant women. British Journal of Medical Psychology. Cambridge University Press, 70 (4): 359-372. Bowlby, John (1997) Attachment and loss. Volume 1: attachment. London: Pimlico.
Bowlby, John (1997) Attachment and loss. Volume 1: attachment. London: Pimlico.
Bowlby, John (1997) Attachment and loss. Volume 1: attachment. London: Pimlico.

Types of attachment

Types of attachment

A child's need for attachment is part of the process of seeking safety and security from their caregiver.

What does secure attachment look like?

In secure caregiver-child relationships, the caregiver is usually sensitive and tuned in to the child's needs. They are able to provide care that is predictably loving, responsive and consistent.

Young children who have formed a secure attachment to their caregiver may display the following patterns of behaviour during times of stress or exploration:

proximity maintenance - wanting to be near their primary caregiver

safe haven - returning to their primary caregiver for comfort and safety if they feel afraid or threatened

secure base - treating their primary caregiver as a base of security from which they can explore the surrounding environment. The child feels safe in the knowledge that they can return to their secure base when needed

separation distress - experiencing anxiety in the absence of their primary caregiver. They are upset when their caregiver leaves, but happy to see them and easily comforted when they return

Benefits of secure attachment

When caregivers react sensitively to ease their child's distress and help them regulate their emotions, it has a positive impact on the child's neurological, physiological and psychosocial development (Howe, 2011).

Children with secure attachments are more likely to develop emotional intelligence, good social skills and robust mental health (Howe, 2011).

Effects of insecure attachment

Not receiving comfort and security in the early years can have a negative effect on children's neurological, psychological, emotional and physical development and functioning (Newman, 2015).

Babies and young children who have attachment issues may be more likely to develop behavioural problems such as attention deficit hyperactivity disorder (ADHD) or conduct disorder (Fearon et al, 2010).

Children who have attachment issues can have difficulty forming healthy relationships when they grow up. This may be because their experiences have taught them to believe that other people are unreliable or untrustworthy (Bowlby, 1997).

Adults with attachment issues are at a higher risk of entering into volatile relationships and having poor parenting skills, behavioural difficulties and mental health problems (Howe, 2011).
> Find out more about how trauma affects child brain development
Further reading

Take a look at our reading list on child attachment.
> View the reading list on the NSPCC Library catalogue

Attachment issues

Attachment issues

Factors affecting attachment

Some circumstances can make it more challenging for a child and their caregivers to form a pattern of secure attachment. These may include:

abuse, maltreatment and trauma experienced by the parent or child

parental mental health difficulties

parental substance misuse

the child having multiple care placements

parents being separated from their baby just after birth, for example if the baby is receiving neonatal care

stress such as having a low income, being a single parent, or being a young parent

bereavement or loss of another caregiver that a child had an attachment with

Signs that a child may have attachment issues

Children's behaviour can be influenced by a wide range of circumstances and emotions.

Indicators that a baby or toddler might not have a secure attachment with their caregiver will emerge as a pattern of behaviour over time, particularly during moments of stress or exploration. This pattern might include:

being fearful or avoidant of a parent or carer

becoming extremely distressed when their carer leaves them, even for a short amount of time

rejecting their caregiver's efforts to calm, soothe, and connect with them

not seeming to notice or care when their caregiver leaves the room or when they return

being passive or non-responsive to their carer

seeming to be depressed or angry

not being interested in playing with toys or exploring their environment

As children with attachment issues get older, these behaviour patterns might evolve. As well as being evident during times of stress, some behaviours may start to become obvious at other times. These may include the child:

finding it difficult to ask for help

struggling to form positive relationships with adults and peers

struggling to concentrate

struggling to calm themselves down

both demanding and rejecting attention or support at the same time

becoming quickly or disproportionately angry or upset, at times with no clear triggers

appearing withdrawn or disengaged from activities

daydreaming, being hyperactive or constantly fidgeting or moving

(Mentally Healthy Schools, 2020).

If you think a child may have attachment issues, you should refer them to a suitably trained health and social care professional for a full assessment. You should follow your organisation's procedures to make a health and social care referral, or contact your local authority children's social care services.

References

Bowlby, John (1989) The making and breaking of affectional bonds. London: Routledge. Mentally Healthy Schools (2020)
Howe, David (2011) Attachment across the lifecourse: a brief introduction. Basingstoke: Palgrave Macmillan.
Attachment and child development. [Accessed 09/11/2020].

Trauma and attachment

Trauma and attachment

The signs of attachment issues can be similar to indicators that a child is experiencing other challenges, such as:

This means it's important to consider everything that's going on in a child's life and make sure they and their family are provided with appropriate support.

Think about all your previous experiences with the child and their caregivers, to help you build a clear picture of their relationships and recognise any concerning patterns of behaviour.

The impact of trauma and attachment

Children who have experienced abuse, neglect and trauma might develop coping strategies that can make it more complicated to recognise attachment issues.

For example, one sign of secure attachment is that children see their caregiver as a secure base to explore from. But children who have experienced neglect, for example, might display independent behaviour in order to protect themselves from the emotional pain of not having their needs met (Marvin et al, 2002).

It is also possible for a child to develop an attachment to someone who is maltreating them (Blizard & Bluhm, 1994).

As well as affecting attachment, experiencing trauma can have an impact on a child's brain development. Children might need extra support to help strengthen the architecture of their brain.
> Find out more about how trauma affects child brain development
What to do if you're worried that a child is experiencing or at risk of abuse or neglect
If a child is in immediate danger, call the police on 999.
If you're worried about a child but they are not in immediate danger, you should share your concerns.

Follow your organisation's child protection procedures without delay. These should provide clear guidelines on the steps you need to take if a child discloses abuse. They will state who in your organisation has responsibility for safeguarding or child protection and who you should report your concerns to.

Contact your local child protection services. Their contact details can be found on the website for the local authority the child lives in.

Contact the police. They will assess the situation and take the appropriate action to protect the child.

Contact the NSPCC Helpline on 0808 800 5000 or by emailing help@nspcc.org.uk. Our child protection specialists will talk through your concerns with you, give you expert advice and take action to protect the child as appropriate. This may include making a referral to the local authority.

> Find out more about recognising and responding to abuse
If your organisation doesn't have a clear safeguarding procedure or you're concerned about how child protection issues are being handled in your own, or another, organisation, contact the Whistleblowing Advice Line to discuss your concerns.
> Find out about the Whistleblowing Advice Line on the NSPCC website
When you're not sure

The NSPCC Helpline can help when you're not sure if a situation needs a safeguarding response. Our child protection specialists are here to support you whether you're seeking advice, sharing concerns about a child, or looking for reassurance.

Whatever the need, reason or feeling, you can contact the NSPCC Helpline on 0808 800 5000 or by emailing help@nspcc.org.uk

Our trained professionals will talk through your concerns with you. Depending on what you share, our experts will talk you through which local services can help, advise you on next steps, or make referrals to children's services and the police.
> Find out more about how the NSPCC Helpline can support you

Supporting children and families

Supporting children and families

Building positive relationships

It's important for anyone who works with children and families to support parents and carers in building positive relationships with their child. Having positive interaction and play with caregivers can help a child's brain to develop healthily.
> See our early years resources which you can share with parents and caregivers
Video feedback programmes can also be used by specially trained social care professionals to help caregivers improve their interactions with their child. This involves caregivers being filmed when they are interacting with their child and then watching the recording with a trained practitioner, who gives them feedback and helps them build on their strengths.

Support for parents and carers

If parents are struggling with their own issues, it may make it harder for them to bond with their child and provide consistant and responsive care. They may have:

experienced abuse of trauma themselves

drug and/or alcohol dependencies

mental health issues.

> Find out more about parental mental health > Learn more about parental substance misuse
Services for children and families

The NSPCC has many services that children and families can be referred to, from supporting parents and carers in taking care of their children to preventing sexual abuse and overcoming abuse.

Our services might be suitable for children and families you are working with:

Pregnancy in Mind helps parents who are at risk of or experiencing mild to moderate anxiety and depression during pregnancy. The service helps build parents' capacity to provide sensitive, responsive care to their babies and keep these skills developed postnatally and as their children develop
Browse for more services
Further reading

Take a look at our reading list about child attachment interventions, support and treatment.
> View the list on the NSPCC Library catalogue
Supporting children's mental health

Children with attachment issues may have problems expressing or controlling their emotions and forming positive relationships, which might affect their mental health.

It's important to make sure children and young people have access to mental health support.
> Find out more about child mental health > See the NSPCC's advice for parents and carers on how to support their child's mental health
Childline

If a child or young person needs confidential help and advice you can always direct them to Childline. Calls to 0800 1111 are free and children can also contact Childline online. Children under the age of 12 can be directed to the Childline Kids website.

We also have a series of posters and wallet cards you can download for free. These can be printed and displayed in your setting to encourage children to contact Childline if they need to talk.

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Attachment and child development | NSPCC Learning

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Explains why attachment is important as well as the different stages. Includes information on types of attachment, attachment issues and the effect of trauma.

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Reith Lectures Links between Childhood Trauma and Violence 

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Reith Lectures Links between Childhood Trauma and Violence 

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BBC Radio 4 - The Reith Lectures - BBC Reith Lectures 2024 – Four Questions About Violence

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Forensic psychiatrist Gwen Adshead announced as BBC Radio 4’s Reith Lecturer for 2024.

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The Most Powerful Conversation I Have Ever Had: The Secret To Dealing with Any Stressor In Life with Dr Edith Eger

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This week marks the 500th episode of this podcast! And what a journey it’s been! There have been so many conversations that have had a profound impact upon my life and to celebrate

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I wonder if you see me poem by Jessica Beaumont 

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I wonder if you see me poem by Jessica Beaumont 

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I Wonder If You See Me - A Spoken Word Poem About Childhood Trauma

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Dr Dan Siegel Podcast Inner peace and become a better parent 

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Dr Dan Siegel Podcast Inner peace and become a better parent 

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Dr. Rangan Chatterjee MbChB, BSc (Hons), MRCP, MRCGP

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The Science Of Personality: How To Transform Your Life, Find Inner Peace and Become a Better Parent with Dr Dan Siegel | Dr Rangan Chatterjee

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Are you living your life intentionally, or are you simply reacting to the world around you? Do you feel a sense of wholeness and contentment, or are you constantly striving for something more? In today’s episode, I dive into these fundamental questions about the nature of human existence with Dr…

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What is unresolved attachment based trauma and how can it contribute to parenting difficulties?

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Trauma Informed Organisations Northern Ireland example

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Trauma Informed Organisations Northern Ireland example

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SBNI Interactive Toolkit_October 2024 - (FINAL 14_10_24)

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Trauma Risk Management (TRiM) - A model of support for staff following a potentially traumatic event - #WeCareTogether

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We recognise that trauma is individual therefore refers to an event/incident which is impacting upon your life and ability to work in a negative way. Trauma Risk Management (TRiM) - A model of support for staff following a potentially traumatic event

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We love infographics, and we love to make them! Come view some of ours here.

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Today's returning guest is Dr Bessel van der Kolk. Bessel is a professor of psychiatry at Boston University School of Medicine and President of the Trauma Research Foundation. He's also the author of the iconic book, 'The Body Keeps the Score', which first came out over 10 years ago and has sold millions of copies all around the world. In fact, the book has been somewhat of an international sensation and is as popular today as it ever has been.

In this conversation, we discuss the meaning of trauma and how it's different from stress. Bessel shares common signs of trauma and describes how traumatic experiences leave a physical imprint in our bodies, which can contribute to a variety of physical and mental health problems. Interestingly, despite his extensive work with patients who have gone through some quite horrific, traumatic events, Bessel is still very optimistic about the world and what he has seen has deepened his belief and faith in human resilience.

We talk about healing and the many methods and techniques that Bessel has found to be helpful. He explains why he thinks that body-oriented therapies such as yoga can play such a vital role and he also explains why he is so passionate about the new research on psychedelic-assisted therapy - for trauma, depression, OCD, and addiction. He explains how these treatments can essentially 'reboot' the brain, opening up new possibilities for healing.*

Throughout the conversation, we emphasise the crucial role of human interaction and supportive communities in dealing with trauma and fostering resilience. Bessel also offers some valuable advice for parents on raising resilient children.

This conversation really is one of hope and positivity. Yes, sometimes life presents us with some challenging times, but as BESSEL MAKES VERY CLEAR - we ALL have a remarkable capacity to move on, change and heal.

Throughout our conversation, Bessel's message is one of hope and the remarkable capacity of humans to change and heal. He provides practical suggestions for those beginning to address their own trauma, including approaches that are affordable and widely available.

This is a powerful and insightful discussion with one of the world's leading authorities on trauma. I hope you enjoy listening.
*PLEASE NOTE: the psychedelic compounds discussed are illegal in many countries around the world and, as Bessel says, these drugs should only be taken under the guidance of trained healthcare professionals. Disclaimer: The content in the podcast and on this webpage is not intended to constitute or be a substitute for professional medical advice, diagnosis, or treatment.*
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Watch the video version of the conversation here:

Connect with Dr van der Kolk:

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Trauma Research Foundation
Dr van der Kolk's book:
The Body Keeps the Score: Mind, Brain and Body in the Transformation of Trauma
Related Feel Better Live More Episodes:

#336 How Trauma Impacts Your Physical Health & How To Heal From It with Dr Bessel van der Kolk

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How To Heal Your Past, Improve Your Mental Wellbeing & Unlock Your Full Potential with Dr Bessel van der Kolk | Dr Rangan Chatterjee

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Today's returning guest is Dr Bessel van der Kolk. Bessel is a professor of psychiatry at Boston University School of Medicine and President of the Trauma Research Foundation. He's also the author of the iconic book, 'The Body Keeps the Score', which first came out over 10 years ago and...

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Trauma Informed Working (ACE) organisational self assessment 

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Trauma Informed Working (ACE) organisational self assessment 

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Responding to Vicarious Trauma In Supervision Self Assessment Tool 

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Responding to Vicarious Trauma In Supervision Self Assessment Tool 

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How can we care for children who've experienced trauma? What are some of the challenges and what do we need to hold in mind?

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Join Dan Hughes, Kim Golding and Edwina Grant as they chat about the therapeutic, parenting and practitioner attitude of PACE. PACE empowers us to achieve togetherness in working with, around and for children and young people who have experienced relational trauma.

© Scottish Attachment in Action (SAIA), 2022

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Reaching Into the Hurt Child's Mind and Heart with PACE - DDP Network

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Join Dan Hughes, Kim Golding and Edwina Grant as they chat about the therapeutic, parenting and practitioner attitude of PACE. PACE empowers us to achieve togetherness in working with, around and for children and young people who have experienced relational trauma. © Scottish Attachment in Action (SAIA), 2022

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Our lives, our cultures, are composed of many overlapping stories. Novelist Chimamanda Adichie tells the story of how she found her authentic cultural voice -- and warns that if we hear only a single story about another person or country, we risk a critical misunderstanding.

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Linking Overwhelm and developmental Trauma 

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Linking Overwhelm and developmental Trauma 

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Developing emotional Resilience by Grant and Kinman Community Care 

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Developing emotional Resilience by Grant and Kinman Community Care 

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Trauma Informed Capability approach in Youth Services Prof.Hickle 

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Trauma Informed Capability approach in Youth Services Prof.Hickle 

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Reflective Practices for Trauma Informed and culturally competent Supervision

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Reflective Practices for Trauma Informed and culturally competent Supervision

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Working with Parents Research in Practice 

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Working with Parents Research in Practice 

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What are you feeling (Beacon house resource) 

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What are you feeling (Beacon house resource) 

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Trauma Informed Approaches in Children's Services 

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Trauma Informed Approaches in Children's Services 

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As we move through the final stages of the Innovate Project, our thoughts have been turning to what we have learned within our three domains of investigation, which were about: (i) the processes of innovation; (ii) extra-familial risks and harms; and (iii) the three practice and system frameworks of Contextual Safeguarding, Trauma-informed Practice, and Transitional

In this blog Dr Gillian Ruch discusses the challenge of relationships, risk and power being at the heart of innovation in social care contexts.

In our latest blog Dr Carlie Goldsmith, research fellow on the trauma-informed practice strand of the Innovate Project, reflects on the experience of moving ethnography of children's services online. Specifically, she discusses some of the challenges this raises for researchers, especially those involved in highly sensitive research.

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The Innovate Project | Researching youth, risk and complexity

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Exploring how services are addressing extra-familial risks experienced by young people; building new knowledge about the processes of innovation in social care.

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East Sussex and University of Sussex Resource Thinking outside the box 

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East Sussex and University of Sussex Resource Thinking outside the box 

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East Sussex and University Of Sussex What works for Me resource 

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East Sussex and University Of Sussex What works for Me resource 

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By Dr. Peggy Loo
I am lucky to have an outdoor patio. In the spring, there is a great exodus of plants to the patio and caring for my plants becomes a daily source of joy, wonder, and quiet satisfaction. I repot, prune, propagate, and congratulate new leaves for sprouting. I wasn't always a green thumb - in fact, I used to reliably kill any plant that was gifted to me. I would place my new plant by a window and water it - only to discover in a few weeks a wilted or shriveled mess. I assumed plant people had some kind of connection to the earth I must be lacking. Later on, I discovered it was nothing of the sort. Taking care of plants is doable for anyone - if you know what the plant needs and you respond. I had no clue about the basics of plant care. I assumed water and light were sufficient to keep any plant alive; I treated every plant as if it had identical needs. Once I actually took the time to identify what kind of plant I had and its requirements for growth, things changed rapidly. I learned about sunlight direction, soil types, how to recognize when a plant is stressed, root bound, overwatered, or could use some pruning. Each plant was different. When I created the right environment, observed how a plant responded in my home, and adjusted its care accordingly...it began to grow and mature under my care. Now I have dozens of happy plants. Even though all plants need some amount of sunlight and water, they need attentive support that matches its individual needs for growth.

What is childhood emotional neglect?

This can be a helpful analogy for childhood emotional neglect. Childhood emotional neglect occurs when parents or caregivers regularly fail to provide basic emotional support and affection required for a child's emotional development and wellbeing. While all parents are at times distracted, stressed, and imperfect in responding to their children, childhood emotional neglect is a pervasive pattern of dismissal or indifference to a child's emotional distress or feelings. It is chronic misattunement to a child's emotional world.

Emotional neglect is often minimized, even rejected as legitimate trauma because it is so frequently eclipsed by other co-occurring types of trauma. It is a real trauma. The disregard for it is ironic but understandable, as emotional neglect is about the omission, or lack of what was needed, rather than the presence of maltreatment which characterizes other forms of abuse. Physical and sexual abuse are embodied, horrific experiences of harm - there is a physicality to it that you can point to. Even emotional abuse can be recognized by the existence of a serious wrong, such as degradation, threat, shaming, or manipulation. But childhood emotional neglect is different - it is an absence of warm nurturance, attunement, and responsiveness to your emotional experiences and needs. How does a child point to an injury caused by something that failed to happen? As adults, they often don't. I see my adult patients struggle to name emotional neglect or label it as traumatic. Sometimes it's because other traumas take center stage, but sometimes it's because they had a "fine" enough childhood with parental provision and educational opportunity. It can be hard to acknowledge the negative effects of emotional neglect if their parents "did their best", "other people had it worse", or "nothing happened to me".

Emotional support is essential to health & wellbeing

Therein lies the problem. Nothing happened. In the research, emotional neglect is hard to define - which make sense, because you're pointing at a gaping hole as the issue. Emotional connection isn't easily measured nor does it manifest in one way. Add to that the range of cultural differences in parenting, parent-child relationships, and emotional expression and it gets even more challenging. Instead of spending too much time debating whether or not something is considered negative, neglect, or traumatic - I often paint a picture of what should be happening, more or less. Did your parents or caregivers convey interest in you and your experiences? Did they recognize strengths and make you feel loved, valued, seen, and heard? Did they notice your emotional distress and respond with compassion? Did they validate a range of emotions or were certain ones unacceptable? While emotional support may be less visible and hard to fully define, the negative effects of emotional neglect are undeniable.

The effects of childhood emotional neglect

Our emotional development and wellbeing comes from our emotional selves receiving nourishment, guidance, and acceptance. When our parents notice and respond to our feelings as an important part of who we are and our experience, we can become adults that view feelings as valuable and worth reflecting on. When our feelings are ignored, dismissed, or deemed unacceptable as children, as adults we often end up doing more of the same with our emotional experiences. While there are many consequences to emotional neglect, here are a few:

You have difficulty experiencing your emotions.

You may struggle with many aspects of experiencing emotions - naming, validating, understanding or managing them. You may not have a wide emotional vocabulary. In a survey of over 7000 people*, the average number of emotions that people can identify while feeling them is three. You may label some emotions as good and others as bad- and then try to control, suppress, or reject the bad ones. You may be self-critical when you experience intense emotions. You may struggle with self-reflection or having empathy for yourself. You may not know how to integrate your emotions into your daily life and feel somewhat disconnected from your internal world.

You tend to seek reassurance about your feelings.

If you were never told that your feelings were valuable and a wonderful, hard-wired internal compass we all have to navigate life, it can feel like you're walking around lost. If you don't know how to use your emotional experiences to provide you a sense of direction, you are likely to look towards others for reassurance, validation, or comparison to make sense of your feelings. You may have trouble making personal decisions, trusting your instincts, taking appropriate risks, or allowing yourself to feel something without explicit permission from someone else.

You avoid connecting emotionally with others.

You may have trouble choosing intimacy in relationships, as intimacy comes from being able to share feelings vulnerably and responding to each other's emotional needs - in real time. I'm not talking about the situations where you're still feeling someone out as trustworthy or a boundary is a healthy step to take. I'm talking about the relationships you have where opportunities for intimacy and closeness exists, but you avoid taking them. If your own emotional needs were ignored, it may be hard to believe that someone is genuinely interested to hear how you're feeling. You may prefer to be self-reliant. You may prioritize others' emotions over your own and create a dynamic where you are emotionally caretaking (this may feel connecting for them, but caretaking is not the same as mutually connecting). You may only share what you felt in a situation only after it's been resolved, not while it feels "messy" or when you're still feeling vulnerable.

There may be other reasons that you are experiencing the above. However, if you were subject to childhood emotional neglect, acknowledging that those experiences during your formative years affected you deeply (and may even have been traumatic) may be an important connection for you. This can help you view your struggles through a lens you hadn't thought of before.

Multicultural considerations about defining emotional neglect

A note about multicultural differences, and perhaps to people of Asian descent as an Asian American psychologist. I often hear people invalidate experiences of real hurt from childhood because "you know, Asian parents" or some culture-bound explanation of why the way they were treated as a child was no big deal. (First of all, let's get curious about what's happening when we're rationalizing anything away, especially someone else's behavior.) There is an important difference between a cultural norm of emotional restraint and emotional neglect. One has to do with acknowledging the diversity of values when it comes to emotional expression in the world. This can include emotional composure in certain contexts or a cultural preference for less effusive displays of affect. Emotional neglect is about emotional indifference, rejection, or withholding towards someone you have a responsibility to. This is devaluing someone's feelings entirely (when your role includes the expectation of emotional availability), not about degrees of emotional demonstrativeness or sometimes the real need for cross-cultural translation. (Of course one can be emotionally neglectful by being emotionally reserved, but they are not necessarily synonymous). I would argue that it is possible to be emotionally responsive to another person while behaving in a manner that appears externally restrained by some points of reference. For anyone who has grown up with a family member where there was a profound language barrier or simply traveled to a country with obvious cultural differences from your own - you know that warmth, connection, and empathy can be expressed even without shared language, expressions, or customs.

Taking the time to separate intention from impact

One of the the most insidious ideas I've heard that prevents someone from acknowledging a traumatic experience, especially by childhood emotional neglect, is that "they didn't mean it". There are many reasons why a parent or caregiver may have been emotionally neglectful without intention, perhaps even with genuine contrition. They may have struggled with mental health concerns, illness, addiction, their own trauma histories, poverty, toxic masculinity, even a lack of knowledge - all real contributing factors to emotional unavailability. We need to take the time to separate intention from impact. Even if emotional neglect was not intentional, it carries impact. A lack of intention does not erase impact. Intent is certainly relevant, especially for relationship dynamics - but it is not the deciding factor of whether or not impact occurred. If you were drinking water from a hose and someone accidentally stepped on the hose, cutting off the water supply - you go thirsty whether or not it was on purpose.

What can I do if I've experienced emotional neglect?

I'm here to tell you that your feelings matter so very much. And I'm sorry you have ever felt otherwise. A basic step forward is taking the time to name your feelings without judgment. At the end of a day, pause and try and describe some of the emotions you experienced that day. We legitimize our emotions through the process of giving them undivided attention and putting language to them. Something as simple as "I felt X today and that's okay". If you're not sure what you're feeling, find a resource to help. There are countless feeling wheels, handouts, podcasts, and books to learn from.

This does not mean go share the most vulnerable part of yourself with someone else. Try sharing some kind of honest emotional reaction you had in your day with someone else. Part of what is so damaging about emotional neglect is the inherent relationship disconnection it represents. Connecting with others on an emotions-level is a great start. It could be something like "I was feeling nervous about X today" or genuinely answering the question "How are you?" instead of defaulting to "Fine" or describing what you've been doing instead of how you're feeling.

It may be helpful to process the effects of childhood emotional neglect with a trauma-informed therapist. (Or if you're unsure how to make sense of your childhood experiences, it can be clarifying to discuss them with a mental health professional.) It can feel overwhelming to acknowledge what may have been traumatic experiences and address it on your own. Being in therapy can help you learn more about the effects of emotional neglect, make connections, and try new skills with consistent support. Simply committing once a week to being self-reflective with someone who gives their undivided attention as you discuss your internal world may be healing in of itself. If you are already in therapy but have not spoken about this, try bringing it up to your therapist as a possible new focus for sessions. Something like "Can I bring in a new topic for our sessions?" or "I know we've been focusing on X, but I was curious if we could talk about how my feelings overall were treated as a kid".

*https://time.com/6122081/brene-brown-atlas-of-the-heart/

About the Author: Dr. Peggy Loo is a licensed psychologist and the director of Manhattan Therapy Collective. If she weren't a therapist, she would consider a career in writing children's books about emotions.

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What is Childhood Emotional Neglect? Did I Experience Emotional Neglect? - Manhattan Therapy Collective | Cognitive Behavioral Therapists | New York Psychologists

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Childhood emotional neglect occurs when parents or caregivers regularly fail to provide basic emotional support and affection required for a child's emotional development and wellbeing. While all parents are at times distracted, stressed, and imperfect in responding to their children, childhood emot

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Childhood Trauma and the Brain | UK Trauma Council

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Childhood Trauma: The Lives of the Neglected Children

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Qualities of Trauma Informed Supervision 

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Qualities of Trauma Informed Supervision 

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Self Regulation and Regulating with others - Resource from Sussex University 

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Self Regulation and Regulating with others - Resource from Sussex University 

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Introduction to Racial Trauma Resource by Sussex University 

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Introduction to Racial Trauma Resource by Sussex University 

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Trauma Informed Environment resource by University of Sussex and Oasis Project 

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Trauma Informed Environment resource by University of Sussex and Oasis Project 

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Towards Building a Trauma-Informed Environment

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Trauma Informed Ways of writing about a young person 

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Trauma Informed Ways of writing about a young person 

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Recording and Records - Family Stories Mirra Project 

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Recording and Records - Family Stories Mirra Project 

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MIRRA: Memory - Identity - Rights in Records - Access

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By Victoria Hoyle, on 12 June 2018

Personal records, photographs and family stories help people to remember significant events and milestones from childhood: where you went on holiday when you were 7, what part you had in your first school play or when you lost your first tooth. But if you grew up in care these things may be missing or inaccessible. Not only that but you might have a particularly complex personal story, involving lots of foster or residential placements and people coming into your life for brief periods. As a result care leavers often have significant gaps in their stories and unanswered questions about their lives. In the absence of family archives they turn to records held by the local authorities and charities that looked after them. These organisational records are their personal histories, helping to create and reconstruct narratives about the past.

Since the 19 th century vast quantities of information about children and families has been collected as part of social work activity. These files look different depending on when and where you were in care. They may have been produced by lots of people, including social workers, teachers, family, foster carers, residential care workers, health services and the police. In some cases files can run to 1000s of pages. Some may include highly personal things like photographs, letters and school reports while others are official, repetitive and full of jargon. Either way this 'paper self' is hugely important, both for how children and young people are understood and treated while they're in care, and for how they understand and treat themselves later in life.

Asking to see your care file is a big decision that can take years to make and the process is often difficult. Some records have been destroyed and others are lost in confused records management systems. People can wait over a year to receive any information. Where records survive they may be fragmentary, contradictory and contrast sharply with a person's existing memories. Information about family or carers might be blacked out - 'redacted' - and documents sometimes leave out the important emotional details. Photographs, school reports, swimming certificates and other personal documents only survive in about 10-20% of cases. In other words care records often conceal or obscure as much as they reveal. Care-experienced people report feelings of powerlessness, frustration, anger and trauma in trying to recover their childhoods from their files. This isn't the whole story - lots of people find positive things in their records too - but it's definitely a recurring theme.

The Access to Records Campaign Group (a collaboration of voluntary organisations led by The Care Leavers Association) have been making the case for better support and resources for access to records for the last decade. Their 2016 report It's My Journey, It's My Life drew on the experiences of care leavers and social care practitioners, and set out the practical, legal and emotional challenges that face people who access their records. The arrival of GDPR (General Data Protection Regulation) in May 2018 and the role of records in the Independent Inquiry into Child Sexual Abuse (IICSA) has also highlighted the value and complexity of social care files.

MIRRA is a research project that aims to support the rights of care leavers by exploring how child social care records have been created, kept and used in public and voluntary organisations in England from the mid-20 th century to the present day. The acronym stands for Memory - Identity - Rights in Records - Access. It is a participatory action research project co-produced with care leavers in partnership with the Care Leavers Association. Ultimately it aims to make positive changes to social care recordkeeping and through those changes improve the care leavers' experiences.

On this blog we will be sharing our research journey. We will talk in more depth about the project and what we are doing, featuring posts from the research team and from care leavers and others. If you have something you would like to contribute, please do get in touch.

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By Victoria Hoyle, on 12 June 2018 Personal records, photographs and family stories help people to remember significant events and milestones from childhood: where you went on holiday when you were 7, what part you had in your first school play or when you lost your first tooth.

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Good Practice in Recording Research in Practice 

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Good Practice in Recording Research in Practice 

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Good practice in recording and access to records: Strategic Briefing (2022) | Research in Practice

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The briefing offers an overview research in children’s social care record-keeping, drawing on the views of care-experienced people and person-centred recording.

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What is trauma? The author of “The Body Keeps the Score” explains | Bessel van der Kolk | Big Think

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The Importance of Relationships! and Connections! Robert Waldinger

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The Importance of Relationships! and Connections! Robert Waldinger

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Robert Waldinger: The secret to a happy life -- lessons from 8 decades of research

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The happiest and healthiest people are those who have warm connections with others, says psychiatrist Robert Waldinger, who leads the Harvard Study of Adult Development -- one of the longest-running studies of adult life ever conducted.

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Vicarious Trauma and Resilience in teaching 

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Vicarious Trauma and Resilience in teaching 

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'Teachers are at risk of secondary trauma when exposed to details ... about a student's traumatic experiences.' ©Comeback Images/Shutterstock

In our last Teacher survey, many of you told us you'd like more content on trauma-informed practice. In this article, Dr Emily Berger, educational and developmental psychologist at Monash University, shares trauma-informed strategies that teachers can use in the classroom to support both student and teacher wellbeing.

Children exposed to trauma face additional learning and social-emotional problems at school, contributing to teachers' emotional burden and stress. Teachers are often unsure how to manage the needs of these students, whilst also managing their own stress and emotional labour. Limiting emotional distress for teachers exposed to traumatised students is essential to ensure a resilient teaching workforce.

Trauma is a common experience in childhood - 60 to 80% of children will be exposed to a potentially traumatic event by 18 years of age (Copeland et al., 2007; Finkelhor et al., 2009). Types of potentially traumatic events in childhood include exposure to abuse, neglect or maltreatment, domestic violence, living with a parent with mental illness, exposure to disasters, medical procedures and accidents.

These events can severely impact a child's wellbeing, development and learning (Perfect et al., 2016). Children most at risk of negative outcomes from potentially traumatic events are those who have experienced repeated and prolonged trauma, children with prior mental health challenges, and those who lack support systems at home and school (Berger et al., 2022).

With the high proportion of school-aged children having experienced a form of trauma, many teachers will find themselves interacting closely with students who have been traumatised, placing teachers at risk of psychological distress in the school setting. The reactions of teachers can also potentially re-traumatise traumatised students in the school environment.

For example, a child exposed to family violence may experience a trauma reaction if a teacher raises their voice in the classroom or if they are prevented from leaving a certain situation at school. These types of experiences are known to re-traumatise a child. This is because they can remind the child of past traumas, such as violence and anger from adults at home.

Thus, it is important that children exposed to trauma experience supportive and nurturing environments to help them recover and potentially thrive after a traumatic experience.

Trauma-informed classroom strategies

Trauma-informed practice is a recognised evidence-based approach designed to help teachers manage the needs of and support children exposed to trauma. Trauma-informed practice also helps teachers manage the risk of experiencing vicarious trauma. It provides professional development to teachers on the prevalence and impacts of early life trauma in childhood, and methods that teachers can adopt in their classroom to prevent children from experiencing re-traumatisation at school (Berger & Martin, 2021).

Trauma-informed classroom programs include three levels of support: 1) promoting positive teacher-student relationships and routines; 2) teaching students emotional and behavioural regulation skills; and 3) encouraging students to set goals and maintain coping strategies (Berger et al., submitted). This can include things like establishing routines and predictable classroom schedules, getting to know students and their interests, avoiding punitive responses to students' disruptive behaviours, and working with students to understand their learning goals and needs.

Research has found that trauma-informed practice prevents many negative consequences for children exposed to trauma, such as lowering symptoms of depression, anxiety and posttraumatic stress, improving students' school engagement and learning, and improving teachers' knowledge and confidence to implement trauma-informed strategies in their classroom (Berger, 2019).

Evidence-based trauma-informed programs also involve school principals who implement trauma-informed school polices, and school psychologists and counsellors who provide additional support to trauma-affected students and families (Berger, 2019). Research shows that engaging school leaders and mental health staff when implementing trauma-informed programs helps to prevent negative mental health outcomes for teachers when exposed to traumatised students in their classrooms (Dorado et al., 2016).

Trauma-informed programs which involve teachers, school leaders and mental health staff are often referred to as 'whole-school trauma-informed programs' which focus on sharing the load amongst staff of supporting traumatised students to prevent staff burnout and vicarious trauma.

Teachers and vicarious trauma

Secondary trauma (also known as vicarious trauma) is a concept that was first coined approximately 30 years ago when it was observed that service providers expressed symptoms of posttraumatic stress from exposure to details about other people's trauma, without having experienced the traumatic event themselves. This can be through hearing about the details of other people's trauma or responding to the mental health needs and distress of traumatised people over time.

Since then, secondary trauma has been observed among military and law enforcement personnel, doctors, psychologists and social workers, and, more recently, teachers (Berger et al., 2021; Hensel et al., 2015). Teachers are at risk of secondary trauma when exposed to details, especially repeated details, about a student's traumatic experiences.

Trauma-informed practice has been found to reduce symptoms of secondary trauma among teachers. For example, a program designed to respond to secondary trauma symptoms among teachers was found to reduce symptoms of posttraumatic stress and secondary trauma of educators exposed to the 2010 Canterbury earthquake in New Zealand (Berger et al., 2016). The ERASE Stress program includes professional development, skills training and resiliency strategies for educators, enabling them to support themselves and their students in response to critical incidents and events (Gelkopf & Berger, 2009).

Unfortunately, these programs are some of the few examples that have been developed and found to be effective at reducing the onset and symptoms of secondary trauma among teachers.

Strategies for resilience

Vicarious resilience (or vicarious posttraumatic resilience) is a term used in the trauma literature to describe people who do not experience distress as a result of their work with traumatised people. The resilience literature is clear that people show vicarious resilience when they have a number of strengths and coping mechanisms that help them to overcome the stress of knowing about a traumatic experience (Hernandez-Wolfe, 2018).

Resources and coping mechanisms include showing empathy and changing one's perspective on life based on exposure to traumatised people, sharing hope and positive reflections with people exposed to trauma, practices that affirm and support coping strategies of traumatised people, and increasing self-awareness and self-care around one's own coping when working with traumatised people (Hernandez-Wolfe, 2018).

Another review found that to maintain teachers' wellbeing, programs need to promote teachers' individual coping strategies as well as change systemic practices such as a school culture that values teacher wellbeing, leaders who prioritise teacher wellbeing, and school policies that promote teachers' wellbeing (Berger et al., in press).

Ultimately, more programs and policies are required in schools that prioritise teacher wellbeing and centre trauma-informed programs in schools.

Programs and school policies with strategies to enhance the wellbeing of students exposed to trauma and their teachers, effective school leadership, and school and community mental health support can promote a better school climate, enhancing the resilience and recovery of traumatised students and limiting secondary trauma and attrition of teachers.

Berger, E. (2019). Multi-tiered approaches to trauma-informed care in schools: a systematic review. School Mental Health, 11(4), 650-664. https://doi.org/10.1007/s12310-019-09326-0

Berger, R., Abu-Raiya, H., & Benatov, J. (2016). Reducing primary and secondary traumatic stress symptoms among educators by training them to deliver a resiliency program (ERASE-Stress) following the Christchurch earthquake in New Zealand. The American journal of orthopsychiatry, 86(2), 236-251. https://doi.org/10.1037/ort0000153

Berger, E., Bearsley, A., & Lever, M. (2021). Qualitative evaluation of teacher trauma knowledge and response in schools. Journal of Aggression, Maltreatment & Trauma, 30(8), 1041-1057. https://doi.org/10.1080/10926771.2020.1806976

Berger, E., & Martin, K. (2021). Embedding trauma-informed practice within the education sector. Journal of Community and Applied Social Psychology, 31(2), 223-227. https://doi.org/10.1002/casp.2494

Berger, E., Martin, K., Krishnamoorthy, G., Barrett, E., Brunzell, T., Ayre, K., Rees, B., & Wheeler, K. (2022). Trauma-Informed Practice in Schools during COVID-19: Reflections on Programs in Australia. [Manuscript submitted for publication].

Berger, E., Reupert, A., Campbell, T. C. H., Morris, Z., Hammer, M., Diamond, Z., Hine, R., Patrick, P., & Fathers, C. (in press). A systematic review of evidence-based wellbeing initiatives for schoolteachers and early childhood educators. Educational Psychology Review. [ https://doi.org/10.1007/s10648-022-09690-5

Copeland, W. E., Keeler, G., Angold, A., & Costello, E. J. (2007). Traumatic events and posttraumatic stress in childhood. Archives of general psychiatry, 64(5), 577-584. https://doi.org/10.1001/archpsyc.64.5.577

Dorado, J. S., Martinez, M., McArthur, L. E., & Leibovitz, T. (2016). Healthy Environments and Response to Trauma in Schools (HEARTS): A whole-school, multi-level, prevention and intervention program for creating trauma-informed, safe and supportive schools. School Mental Health: A Multidisciplinary Research and Practice Journal, 8(1), 163-176. https://doi.org/10.1007/s12310-016-9177-0

Finkelhor, D., Ormrod, R. K., & Turner, H. A. (2009). Lifetime assessment of poly-victimization in a national sample of children and youth. Child abuse & neglect, 33(7), 403-411. https://doi.org/10.1016/j.chiabu.2008.09.012

Gelkopf, M., & Berger, R. (2009). A school-based, teacher-mediated prevention program (ERASE-Stress) for reducing terror-related traumatic reactions in Israeli youth: a quasi-randomized controlled trial. Journal of child psychology and psychiatry, and allied disciplines, 50(8), 962-971. https://doi.org/10.1111/j.1469-7610.2008.02021.x

Hensel, J.M., Ruiz, C., Finney, C. and Dewa, C.S. (2015), Meta-Analysis of Risk Factors for Secondary Traumatic Stress in Therapeutic Work With Trauma Victims. Journal of Traumatic Stress, 28, 83-91. https://doi.org/10.1002/jts.21998

Hernandez-Wolfe, Pilar. (2018). Vicarious Resilience: A Comprehensive Review. Revista de Estudios Sociales. 66. 9-17. 10.7440/res66.2018.02.

Perfect, M.M., Turley, M.R., Carlson, J.S. et al. School-Related Outcomes of Traumatic Event Exposure and Traumatic Stress Symptoms in Students: A Systematic Review of Research from 1990 to 2015. School Mental Health 8, 7-43 (2016). https://doi.org/10.1007/s12310-016-9175-2

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Resilience at work: Vicarious trauma in teaching and practical...

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Teachers do their best to support student wellbeing, and often this can mean supporting a student who may be showing signs of posttraumatic stress at school. In this article, Dr Emily Berger shares trauma-informed strategies that teachers can use in the classroom to support both student and teacher...

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Trauma-Informed Approaches to Working with Children, Young People and Families

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Oasis Project and Make Good Trouble present: Trauma-Informed Practice: Working with Children/Young People and Families

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Attachment behaviours at School Resource 

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Attachment behaviours at School Resource 

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Beacon House Trauma Informed Resource Pack 

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Beacon House Trauma Informed Resource Pack 

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The power of everyday heroes | Jaz Ampaw-Farr | TEDxNorwichED

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Trauma Informed Schools UK - further training opportunities 

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Trauma Informed Schools UK - further training opportunities 

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Our vision is to provide appropriate training for schools, communities and organisations so that they become trauma informed and mentally healthy places for all.

This means we aim to help children and teenagers BEFORE they get mental health problems - to catch them as they are falling not after they have fallen. Towards this aim we strongly endorse the statement in the Government Green Paper December 2017 Transforming Children and Young People's Mental Health Provision, "There is evidence that appropriately-trained and supported staff such as teachers, school nurses, counsellors, and teaching assistants can achieve results comparable to those achieved by trained therapists in delivering a number of interventions addressing mild to moderate mental health problems (such as anxiety, conduct disorder, substance use disorders and post-traumatic stress disorder)". We are appropriately training school staff to take on this task.

Our objective is to bring about a whole school /organisational cultural shift where the wellbeing of all is the highest priority. We implement many interventions to ensure the relational and emotional health of all. Our interventions are evidence based with the backing of over 1,000 research studies from psychology and neuroscience.

We also believe that for schools to become mentally healthy places for all, the value of well being has to start at the very top, with organisations such as DFE, Ofsted and the Regional Schools Commissioners balancing the scales between outcomes (test scores) and emotional wellbeing. We are working to ensure that there is national recognition of the importance of monitoring the well being of schools and that Governing Bodies, Trust Boards and Directors make staff wellbeing as well as pupil well being a key performance indicator for our schools.

Practitioner Trainings

11 day and 13 days (University route) over two terms

Senior Leads Training

2 days to ensure your school is trauma and mental health informed

Whole School Inductions

Half or whole day to ensure whole school approach to mentally healthy school status

TRAUMA INFORMED SCHOOLS UK (TISUK): KEY CREDENTIALS
Key Credentials

TISUK is a registered community interest company (social work) working in association with the Centre for Child Mental Health: President Sir Richard Bowlby.

TISUK has delivered return to school training in the Covid 19 crisis to over 20,000 staff in school and community organisations across the UK and Ireland, including members of the National Education Union.

TISUK has a University of East London validated course entitled Certificate in Trauma and Mental Health Informed Schools and Communities (Level 5) and Diploma course entitled Trauma and Mental Health in Schools and Communities (Practitioner status).

Sheffield Hallam University includes a compulsory module of TISUK's training in every level and age phase of their initial teaching education. (Over 1000 trainee teachers have received the training). Professor Mark Boylan (Sheffield Hallam University) is presently working in partnership with TISUK to standardise and publish their key assessment tools.

TISUK is an approved provider for DfE funded Senior Mental Health Lead Training.

Over 5000 schools, colleges, early years settings and community settings, have received training from TISUK including: Whole school training, Senior Leads Training, Diploma (Trauma Informed Practitioner training), e-learning e.g. Supporting the Return to School, Working with Trauma in Early Years Settings, Whole School Cultural Shift to a Trauma Informed Culture, Working with Vulnerable Teenagers in Schools.

TISUK has delivered training at whole school and Diploma level in all of the 22 local authorities across Wales. (bilingual materials and training Welsh language trainers).

TISUK has delivered webinar-based training to schools, early years providers, health and community settings across the UK, including county/borough wide subscriptions in Cornwall, Lambeth, South Yorkshire and across Wales.

TISUK has delivered webinar training on Trauma in the Early years: Prevention and Intervention, to over 1500 Early years settings across South Yorkshire and 100 in Lambeth.

TISUK have worked with education teams in two Youth Offending Institutions to embed a trauma informed approach within each department, with the aim to also train the wider prison staff.

TISUK has delivered introductory Trauma Informed Schools training across West Africa, to school counsellors based in international schools.

TISUK has supported and delivered trauma informed training to Domus Solis & Gravitas Schola who evacuated a whole school community of 300 children, teachers and families from Kharkiv, Ukraine to Vilinus, Lithuania. The school has since been joined by a further 150 children from across Ukraine.

TISUK has worked in association with the Trauma Release and Wellness Centre, to deliver whole staff and senior lead training to schools in Pakistan.

TISUK has an extensive group of eminent consultants and advisors. Several of these have lived experience, and provide expert advice on how schools and communities can work to prevent gang membership, violence, homelessness, prostitution, drug and alcohol addiction.

TISUK's training is highlighted in the DfE Advice to Schools: Mental Health and Behaviour in Schools DfE-00327-2018 as supporting and promoting positive mental health.

TISUK trainings are informed by and adapted from the key components of whole school cultural change as set out by the Evidence-Based Practice Unit, Manchester University/Anna Freud Centre, (Demkowicz and Humphreys 2019). These components comprise of mental health approaches to teaching and learning; pupil/ student voice; staff and senior lead development; health and wellbeing; online assessment tool to ascertain mental health needs and provide a measurable evidence-base of impact; training key members of staff to support vulnerable children through therapeutic conversations; working with parents to support mentally healthy cultures at home.

As a result of our trainings, which were created in reponse to the major cutbacks in CAMHS, we have been thrilled to see so many schools willingly pick up the mental health baton, resulting in fewer exclusions, a reduction in staff stress-related illness and an increase in pupil attendance, attainment and in staff retention. We therefore fully endorse the 2017 Government Green Paper on Children's Mental Health Provision in stating that, 'There is evidence that appropriately trained and supported staff... teachers... teaching assistants can achieve results comparable to those achieved by trained therapists in delivering a number of interventions addressing mild to moderate mental health problems.' That said, our trained staff recognise limits of competence and know when to refer on and to whom.

TISUK has an awards scheme for those schools who wish to be formally assessed for mentally healthy and trauma informed school status.

For the equivalent of just one Pupil Premium Plus grant, TISUK can provide a menu of training options (e.g. Whole school/Senior Leads training/Practitioner Diploma) to support a whole school understanding of mental health informed practices, all designed to benefit everyone in your school (staff and pupils), and directly attributable to the PP+ allocation/spend. Interventions are all practically based, time preserving and cost effective.

Offering support for schools and settings in times of crisis. For example, offering support to students, staff and parents after the tragedy of suicide. Developing a model for whole community support.

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Our vision is to provide appropriate training for schools,communities and organisations so that they become trauma informed and mentally healthy places for all.

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Self Care for Foster Carers paper FINAL.pdf (thefosteringnetwork.org.uk)

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Study on foster carer compassion fatigue

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Study on foster carer compassion fatigue

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compassion-fatigue-and-foster-carers-research-summary.pdf (bristol.ac.uk)

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When the Adults Change - Everything Changes 

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When the Adults Change - Everything Changes 

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Our training team is steeped in relational practice. Many have worked with Paul for more than 10 years. However you blend your training - books, online courses, coaching, training or keynotes - the values of the team ripple through everything. WTAC Trainers are committed to practice that addresses the poverty attainment gap. Their work is inspiring. They seek to develop cultures where wellbeing is distributed evenly and where relational connection leads to engagement in learning.

When you learn with us, you will find behaviour advice that is trauma educated, attachment aware & nurture driven. Everything begins with Paul's best selling books, 'When the Adults Change, Everything Changes' & 'After the Adults Change, Achievable Behaviour Nirvana', the principles of which sit at the core of our online learning programmes and at the heart of our practice.

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When the Adults Change is founded by Paul Dix - a behaviour specialist, author, education reformer and advisor.

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Trauma Informed Environmental Scanning Tools 

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Trauma Informed Environmental Scanning Tools 

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Trauma Informed Schools Environment Checklist New Orleans 

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Trauma Informed Schools Environment Checklist New Orleans 

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Trauma Informed Lancashire - Resources including evaluation tools 

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Trauma Informed Lancashire - Resources including evaluation tools 

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Downloads | Trauma Resources | Trauma Informed Lancashire

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Resources We have a range of resources available to support you on your trauma informed journey. Be sure to check back as our resources library grows and contact us if there are resources you would like to see included.

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Multi-agency Practice Principles for responding to child exploitation and extra-familial harm

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Multi-agency Practice Principles for responding to child exploitation and extra-familial harm

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Multi-agency Practice Principles for responding to child exploitation and extra-familial harm

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The Tackling Child Exploitation (TCE) Programme improves strategic responses to child exploitation and extra-familial harm across England

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An experience of accessing care records 

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An experience of accessing care records 

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I slide the care file out of the messy stack of papers by my bed and place it next to me. It's never far away. It's why when I went travelling for two years in my mid-twenties that it was the first item I stuffed in my rucksack. 'Only take what you need' a friend had said, 'You have to travel as light as possible'. I needed it. 126 pages wrapped in a thin red plastic A4 ring binder. Its contents made up of various reports and reviews from social workers, Children's Services managers, foster carers, psychologists and a police report. So many different voices taking turns to talk out my life, but my own strangely silent, except for a sentence or two scattered here and there. So many versions of me, some I recognised, and others I did not. Most looking like the reflection of a funny fairground mirror, all warped and bent out of shape.

It is clear when reading the file that its authors may not have considered the boy they were writing about might one day read their words. That he might unexpectedly receive the file at the age of 22 in the post and find himself reading it on the way to work on the 126 bus making its way through the rain.

I remember opening up the folder and seeing on the first page a chronology of all my moves while in care. Dates, addresses, foster parent names, the names of children's homes and sometimes the names of other foster children in the same household. An explosion of images and sounds, like fragmented film clips all stitched together, suddenly hit me. I was unprepared. I grabbed for my hood, lifted it over my head and dragged it down over most of my face, but kept reading. I couldn't stop.

There had been no call to warn me the file was coming. No offer of support for someone to sit with me when it came, to guide me through it, to prepare me for the content, for the feelings that were to come, to tell me to be careful and to be kind to myself. There was nobody, no advice, no one to contact when the memories got the better of me in the weeks, months and years that followed. I felt alone. That nine-year-old boy all over again, but now an adult. Both of us reading and remembering, hoods up, in tears.

Six months earlier I had contacted the council that was responsible for me while I was in care. I'd heard in a work training session that a person had the right to access any records that included personal information about them. There must be records on me I thought. The woman from the council said maybe and she would look into it. After making the call I quickly forgot about the request. Months past and then one morning I found myself signing a postman's soggy form and being given a brown package.

That was 20 years ago. I'm now married and have two children, I have a house, a job I'm proud of at a university, and friends that mean the world to me. I've repaired some of the damage between myself and my family, but some remains and we carry those scars silently. Still, from time to time I pick up the file and read bits and pieces. The experience now as a 42-year-old man is different. I'm changing and because of that so is the file. I see it now through new and more experienced eyes. But it is still difficult to read. I think of my own children. My son, almost nine, the same age I went into care permanently.

While it is a difficult document to read, it is also fascinating. Even the difficult elements create doorways into the past and I see the boy riding his BMX on his old estate jumping off the curbs. I see him running around the common with his foster parent Michael, standing in the sea in Jamaica catching the rain in his mouth as the clouds open up, and then holding hands with Caroline while playing hide and seek in the dark.

The file is a complex document full of omissions, but it is also a treasure trove of memories. How many people will ever possess such a document about their childhood? I feel lucky to have it now. I've created a relationship with it that continues to evolve. I've read it hundreds of times and in hundreds of states. I now see in-between the words, into the nooks and crannies of the reports. I see the social workers trying their best and perhaps struggling. I see my bad behaviour misunderstood and I see lost opportunities. I see heroes. I see more and more each time I return to it.

I continue to try my best to let go of the pain the file can generate. It gets tiring holding on to it. The little boy deserves more, but there are still times when I need to talk to someone. In the past, it has been unclear where that support might be. So much of the information and guidance related to the care experience has been fragmented. There's a lack of consistency and so much can depend on what part of the country you were in care. Some councils are better than others, some services more proactive. It can get confusing. There is also further confusion as rights and services can differ based on your care experienced status...were you in care for a short period, a longer period, were you adopted or not. It can be a bit of a minefield that can put many people off.

However, recently I joined a number of other care experienced individuals to support Family Action to develop their new Family Connect website that is the kind of resource I wish I could have accessed all those years ago when I first thought about seeking my records. It is a place that not only supports one accessing their records but also importantly considers the broader issues that can impact this process, such as searching and reengaging with family members and supporting everyone through this process. Family Action has taken great care to develop this resource and my ultimate hope is that people will find it, use it and get support.

You can hear in more detail the process of accessing care records and the importance of child-centred recording in a connected podcast.

Related Research in Practice resources

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An experience of accessing care records | Research in Practice

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I slide the care file out of the messy stack of papers by my bed and place it next to me. It's never far away. It's why when I went travelling for two years in my mid-twenties that it was the first item I stuffed in my rucksack.

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Trauma Informed Care in Residential Care 

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Trauma Informed Care in Residential Care 

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What Works - evidence of Trauma Informed Care in Residential care 

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What Works - evidence of Trauma Informed Care in Residential care 

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Frameworks used at an organisational level to enable trauma-informed practice.

Outcome

Overall
effectiveness

This rating shows how effective the intervention is at achieving the evaluated outcome.

Click here for information about how effectiveness ratings are applied.

Strength of
evidence

This rating shows how confident we can be about a finding, based on how the research was designed and carried out.

Children's behaviour

Overall effectiveness: 1 (maximum 2)

Strength of evidence : 0 (maximum 3)

Headline points

This summary comes from the original systematic review: Bailey, C., Klas, A., Cox, R., Bergmeier, H., Avery, J., & Skouteris, H. (2019). Systematic review of organisation‐wide, trauma‐informed care models in out‐of‐home care (Oo HC) settings. Health & social care in the community, 27(3), e10-e22

Very limited evidence that trauma-informed models improve outcomes for children in out-of-home care

Strength of the evidence is weak with a high risk of bias in six of the seven studies

All studies were conducted in the US. It is unclear whether these interventions would be successful outside of that context

Useful contacts

What is this?

There is widespread recognition that the experience of trauma can have adverse effects on children's development, including both health and social outcomes. Therapeutic and trauma-informed models of care are, therefore, increasingly being adopted within out-of-home care settings. Three interventions were included in the review. All focus on the provision of frameworks (or guiding principles) that enable more trauma-informed practice to be embedded into organisations.

How is it meant to work?

The models provide a framework (or guiding principles) for an organisation to adopt. All interventions are designed to be applied at an organisational level. They include actions for everyone from the CEO to administrative staff. Although the three interventions differ in their exact approach, they broadly include the introduction of structures, processes, and practices that are designed to change the culture of the organisation to reduce the negative impacts of trauma.

What are the evaluated outcomes?

How effective is it?

The outcomes reported are inconsistent between the seven studies, they include general child behaviour, mental health symptoms, aggression and coping skills. Although a generalisation, they can broadly be described as 'children's behaviour'.

Children's behaviour

Seven studies were reviewed. The studies report promising signs of improvements in children's behaviour. However, the strength of the evidence is very weak. Therefore, the overall conclusion is that there is limited evidence that trauma-informed models improve children's behaviour.

The reasons the evidence is classified as being 'very weak' are:

Five studies were considered to have a high risk of bias. The design of these studies were considered weak due to high drop-out rates, a lack of control or comparison group and that the intervention was not always implemented as intended.

Only one of the studies was considered to have a moderate risk of bias because it implemented the intervention in different residential units and different points in time. This created an opportunity for comparison groups.

Where has it been studied?

All three interventions were developed in the US. There is evidence that Local Authorities are adopting these practices, however, the review did not include any evaluations from the UK. In fact, all seven studies included in the review were conducted in the US and it is, therefore, unknown whether these interventions would be successful outside of the US context.

Who does it work for?

The models have been used with a wide age range, from 3-year-olds to adult populations. The review suggests that trauma informed models are not restricted to a certain age range, however, no formal analysis has been conducted.

As the studies report ethnicity differently, the suitability of the models for particular ethnic groups cannot be determined.

When, where and how does it work?

The models have been used in a variety of settings. They include, residential, non-residential, child protection teams, adoption teams, residential care homes and psychiatric hospitals. The relative effectiveness in different settings has not been tested.

It is suggested that for the models to work they must be implemented at an organisational level with change occurring through all levels of staff.

What are the costs and benefits?

No economic analysis was conducted as part of the review.

How is it implemented?

ARC

How is it implemented?

The three domains of intervention in the ARC model are:

Attachment: Strengthening the caregiving system surrounding children through enhancing supports, skills, and relational resources for adult caregivers.

Regulation: Cultivating awareness and skill in identifying, understanding, tolerating, and managing internal experience.

Competency: Building resilience in stress-impacted populations.

ARC is a framework that includes a set of principles that organisations integrate into their approach to working with children and families. Each organisation may choose to use ARC differently depending on the context they are working.

How is it delivered?

ARC isn't an intervention in the traditional sense. It is a framework for organising approaches and a set of principles, of which some or all, can be integrated in practice.

Who can deliver it?

The ARC models has been applied in a wide variety of settings. The approach is not specific to a professional group.

What are the training and supervision requirements?

There is no formal certification process. However, ARC trainers and consultants can support an organisation to implement the ARC model.

What supports good implementation?

The available information suggests the approach is flexible to an organisation's specific context and a definition of good implementation seems fairly varied.

CARE

How is it implemented?

The Children And Residential Experiences (CARE) model is built on six principles:

Developmentally focused

Family involved

Relationship based

Competence centered

Trauma informed

Ecologically oriented

Over a three-year period, CARE experts work closely with an organisation to implement and integrate the CARE practice model. Implementing CARE involves:

Identification of an implementation and integration work group

An assessment of culture/climate, current practice, and program

Training

Technical assistance

How is it delivered?

As with the other models, CARE is not an intervention in the traditional sense. It provides an approach that an organisation can take to change culture towards trauma informed practice.

Who can deliver it?

CARE is specifically designed for residential child care and organisations providing services to children and families. The training is delivered by CARE trainers from Cornell University.

What are the training and supervision requirements?

Training is delivered three to four times per year over a three-year period. Organisation are required to enter a three-year contract with the training provider (Cornell University).

What supports good implementation?

Available information suggests the implementation support provided by the CARE trainers is as important as the efficacy of the CARE model. Further, it requires commitment and change from all levels of staff.

The Sanctuary Model

How is it implemented?

The Sanctuary Model consists of four Pillars:

Shared knowledge (six domain of knowledge)

Shared values (seven commitments)

Shared language (an approach to practice - Safety, Loss, Emotions, Future i.e. SELF framework)

Shared practice (use of the sanctuary toolkit)

The pillars provide a framework for an organisation to follow to change culture. Within the pillars there are a set of practical tools.
How is it delivered?
The Sanctuary Model is not an intervention in the traditional sense. It a whole-system approach that changing culture towards the management of trauma. It requires organisations to not only engage in the practical activities (e.g. training to build and embed knowledge and approaches such as 'Red Flag reviews') but for all individuals in an organisation to adopt the Sanctuary Model perspective (or way of thinking) about trauma informed care.

Who can deliver it?

The materials for implementing the Sanctuary Model are available to purchase online.

What are the training and supervision requirements?

Once purchased, the materials seem to be self-service guides and manuals for implementing the Sanctuary Model. There is not a clear process for formal certification, however, the website does outline 'characteristics of a certified sanctuary organisation'.

What supports good implementation?

The website states that "whether or not Sanctuary "works" is entirely dependent on the ways in which groups of people implement the methodology we have developed" suggesting that commitment and adherence to the model is critical.

Case study

In summary...

Very limited evidence that trauma-informed models improve outcomes for children in out-of-home care

Strength of the evidence is weak with a high risk of bias evident in six of the seven studies

All studies were conducted in the US. It is unclear whether these interventions would be successful outside of that context

Further resources

This summary is based on the original systematic review
Bailey, C., Klas, A., Cox, R., Bergmeier, H., Avery, J. and Skouteris, H. (2019). Systematic review of organisation‐wide, trauma‐informed care models in out‐of‐home care (OoHC) settings. Health & social care in the community 27(3), 10-22

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Trauma-informed models in out-of-home care - What Works for Children's Social Care

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Trauma Informed Communication in Nursing 

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Trauma Informed Communication in Nursing 

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It is important for nurses to engage in communication from a trauma-informed approach, which involves integrating an understanding of the need for:

physical and emotional safety

choice and control

empowerment

(Trauma-Informed Practice Guide, 2013, p. 12).

A trauma-informed approach can be used as one part of therapeutic communication. It involves emphasizing confidentiality, identifying the interview purpose, letting the client set the pace of the interview and shaping it based on their needs, and engaging in collaborative intervention so that the client is in control and empowered. As you apply this approach, you should always be thinking about how you can promote safety, control, and choice for the client.

Given how pervasive trauma is in clinical practice, a trauma-informed approach makes sense to incorporate into your communication and way-of-being with clients. This kind of approach is especially useful because you will often not know who has experienced trauma or the circumstances of their trauma. Trauma includes the emotional consequences of a distressing event (Centre for Addiction and Mental Health [CAMH], n.d.). Many circumstances can lead to trauma, including child abuse and neglect, sexual assault and intimate personal violence, bullying and harassment, as well as events such as car accidents, a death of someone close to you, natural disaster, and war.

Because the trauma-informed communication approach assumes the presence of trauma, it does not require the client to disclose their experience and thereby risk re-traumatizing them through repeated disclosure (Trauma-Informed Practice Guide, 2013).

See Case Study 1 for an example of a trauma-informed approach to interviewing.

Case Study 1

A 19-year-old client presents alone at urgent care. The reason for seeking care noted on the client's chart is: pain, swelling, and bruising on index and middle digits of the left hand, suspected fracture. Upon entry into the examination room, the nurse observes healed bruising under the client's right eye and contusions on the client's neck.

RN: Hello Franco Alonso, my name is Pita Kora, I will be your registered nurse today. You can call me Pita and my pronouns are she/her. What would you like me to call you and what pronouns do you use?

Client: Franco and he/him is fine.

Rationale: Introduce self using first and last name and explains designation - this action promotes accountability for your actions, as it demonstrates that you are taking responsibility through disclosure. Asking what the client would like to be called and their pronouns contributes to the client's sense of control and wellbeing. It also conveys respect for their chosen identity.

RN: Everything we talk about will remain confidential and will only be discussed among healthcare team members involved in your care.

Rationale: This emphasizes confidentiality, including the parameters of who will be privy to the information. This is important to disclose and does not mislead the client to believe that any information they provide will end with you. Indeed, as a nurse you are required to report the data you collect. This honesty is especially important in a trauma-informed approach to build trust and ensure safety.

Client: Ok

Rationale: In this case, you wait for the client to acknowledge your statements, which conveys respect.

RN: Today I will ask you some questions related to your injury and then I will conduct a physical assessment. I will explain all steps as I go along. It will take about 15 or 20 minutes. Does that work for you?

Client: I think so...

Rationale: By proving the client with the purpose and general plan of the interview, you share control and minimize unpredictability. By asking the client if it works for them, you include them in the process and convey collaboration. Certainty and control are important parts of creating a safe space for dialogue.

RN: Can you tell me about what happened to your fingers, Franco?

Client: They were crushed in a car door. It really hurts. I think it may be broken.

Rationale: In this case, you ask an open-ended question without assumptions. This approach is better to begin with than a series of closed-ended questions directed by you. In this case, it is important to allow the client to share their story in their own words.

RN: Ok. I'm sorry to hear. That sounds painful. We will assess for any fractures. How long ago did this happen?

Rationale: You express empathy by responding to what the client said, instead of how the fingers look. It is important to respond to what the client is telling you to build trust. Also, the statement "we will assess for any fractures" offers the client reassurance that the injury will be attended and also acknowledges the initial concern that "it may be broken." It is important to acknowledge the client's concern and not dismiss their concern.

Client: Last week. I didn't think much of it at first, but the swelling hasn't gone away and the bruising seems to be getting worse. I wasn't sure if I should come.

RN: Ok, sure, I can understand that. I noticed some other bruises under your right eye and on your neck. Are they related to your finger injury?

Rationale: You convey empathy by stating that you can understand the client's choices/decisions without judgement. You ask a closed-ended question about other injuries but should allow the client to respond at their pace.

Client: Not really. I mean it happened around the same time but they aren't related.

RN: Ok [allow for silent pause].

Rationale: Silence can be a powerful form of communication. It works in two ways in a trauma-informed approach: first, it conveys to the client that you are unhurried and invested in what they are saying; second, it can give the client an opportunity to think through their responses, which can alleviate pressure on the client and promote their self-determination.

Client: It's kind of a long story. I'm sure you're busy.

RN: I'll make time. Tell me more.

Rationale: The client may be testing your interest and investment to gauge the level of trust. It is important to foster trust within the client and let them know you are reliable. If this isn't possible at that moment, explain to the client why you may not have the time but when you will have the time. For example, "I have an urgent matter down the hall, but I will return in 5 minutes to discuss further." In such cases, it is important to follow up on your promise and not let the client down, because this is likely to damage any trust built.

Summary

A trauma-informed approach creates a safe space for clients to engage in conversation and fosters control and choice. It does not require the client to disclose trauma. However, it creates a space in which the client may feel safe to speak about trauma, if relevant, at their own pace.

Activity: Check Your Understanding

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It is important for nurses to engage in communication from a trauma-informed approach, which involves integrating an understanding of the need for: physical and emotional safety choice and control empowerment (Trauma-Informed Practice Guide, 2013, p. 12). A trauma-informed approach can be used as one part of therapeutic communication.

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Key Ingredients for implementing trauma informed care 

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Key Ingredients for implementing trauma informed care 

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Trauma Informed Primary Care Communication Model 

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Trauma Informed Primary Care Communication Model 

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Fam Med. Author manuscript; available in PMC 2015 Feb 4.

Published in final edited form as:

Bonnie L. Green, PhD, 1 Pamela A. Saunders, PhD, 1 Elizabeth Power, MEd, 2 Priscilla Dass-Brailsford, EdD, 1 Kavitha Bhat Schelbert, MD, MS, 3 Esther Giller, MA, 4 Larry Wissow, MD, MPH, 5 Alejandra Hurtado-de-Mendoza, PhD, 1 and Mihriye Mete, PhD 6

Abstract

BACKGROUND AND OBJECTIVES:

Trauma exposure predicts mental disorders, medical morbidity, and healthcare costs. Yet trauma-related impacts have not received sufficient attention in primary care provider (PCP) training programs. This study adapted a theory-based approach to working with trauma survivors, Risking Connection, into a 6-hour CME course, Trauma-Informed Medical Care ( TI-Med), and evaluated its efficacy.

METHODS:

We randomized PCPs to training or wait-list (delay) conditions; waitlist groups were trained after reassessment. The primary outcome assessing newly acquired skills was a patient-centeredness score derived from Roter Interactional Analysis System ratings of 90 taped visits between PCPs and standardized patients (SPs). PCPs were Family Medicine residents (n=17) and community physicians (n=13; 83% Family Medicine specialty), from four sites in the Washington DC metropolitan area.

RESULTS:

Immediately trained PCPs trended toward a larger increase in patient-centeredness than did the delayed PCPs (p < .09), with a moderate effect size (.66). The combined trained PCP groups showed a significant increase in patient-centeredness pre to post training, p < .01, Cohen's D = .61.

CONCLUSIONS:

This is a promising approach to supporting relationship-based trauma-informed care among PCPs to help promote better patient health and higher compliance with medical treatment plans.

Keywords: trauma, communication, continuing medical education, patient-centeredness

INTRODUCTION

The general population experiences substantial exposure to traumatic events (50-75%). 1-3 Trauma is linked to mental disorders, including posttraumatic stress disorder (PTSD), and interpersonal problems. 4-6 Interpersonal trauma is high among primary care patients 7-9 and current PTSD may affect up to 23%. 10-13 Trauma, adversity, and PTSD predict increased healthcare costs 8,14 and negative health outcomes, 3,8 including chronic cardiac and pulmonary diseases, 3,15-17 and disability and severity. 18,19

Although trauma-exposed patients are common in primary care, 20,21 many primary care providers (PCPs) report discomfort discussing trauma and its health effects, and feel unprepared to do so. 22-25 Patients with histories of trauma, including those with PTSD, report more negative provider interactions and perceptions. 26,27 Training of non-psychiatric physicians in trauma-informed care therefore appears to be a necessary, if not sufficient, condition to improve services to survivors. Trauma survivors may be impaired in forming and maintaining trusting relationships, and are often sensitive to issues of how power and authority are used in relationships. As the patient's care team coordinator, PCPs must effectively support patients who, because of their response to trauma, are challenged by their healthcare experiences and interactions with healthcare providers. Training needs in the care of trauma survivors are potentially high in medical schools and residencies, 28-31 yet few programs address communication with trauma survivors, or associated PCP discomfort.

Good communication practices are central in primary care, and influence patient satisfaction, medical information recall, and compliance with recommendations. 32-35 Physician communication predicts physiological, behavioral, and emotional outcomes. 36-38 We are aware of only one other randomized controlled trial 39 for PCPs that incorporated trauma awareness into communication training. This study showed significantly higher patient-centered communication and discussion of adverse childhood events in trained PCPs versus controls a year later. Our study complements this one by integrating the trauma training into the overall training and by including medical residents.

Communication training programs targeting resident physicians can create higher standards of professional behavior to which physicians may adhere throughout their careers. Communication training for residents can improve knowledge, attitudes, and interviewing skills,40 partnership building, and empathy. 41 Training for practicing physicians also affects patient perceptions of providers, satisfaction, and health behaviors, even when the training is relatively short (less than 10 hours). 42 The current concept/pilot study adapted and tested a theory-based, evidence-informed approach to communicating and relating with trauma survivors, Risking Connection (RC), into a 6-hour CME course for resident and practicing PCPs called Trauma-Informed Medical Care (TI-Med). Based on our training goals, our outcome was trauma-informed, patient-centered communication, with the PCP addressing psychosocial topics, attending to the doctor-patient partnership, 39 and focusing on respect for the patient's values, preferences, and needs, and including education, information, and support. 43

METHOD

The training offered in our study is a derivative of the RC curriculum, 44 a strength-based approach to understanding and responding effectively to the needs of people who have been wounded in interpersonal relationships. The training model teaches clinicians, agency-based service providers, and frontline helpers of all types how best to respond to survivors of interpersonal trauma such as child abuse. RC focuses on the qualities, values, and skills for building relationships as the keys to promoting healing, and it also emphasizes that helpers must attend to self-awareness and self-care. RC has a delivery and implementation history in mental health settings, congregate care environments, faith communities, and medical facilities. 45,46 Its theoretical basis is relational-cultural theory 47 and McCann and Pearlman's Constructivist Self-Development Theory, which elaborates the encoding of a trauma and its relationship to aspects of the self. 48

While audience requirements result in different instructional strategies, all derivative works align with the core content. Thus, the training provided to PCPs in this study met the same objectives as the training offered in all other settings, even though the instructional strategies and delivery context were different. Elements of evidence-based learning were incorporated, including the use of a detailed, realistic case study introduced at the beginning of training and advanced throughout the curriculum. 49

Adaptation Process

The adaptation followed Weisz and colleagues. 50 Revisions of the manual and training curriculum incorporated input from targeted PCPs and patients, i.e., low-income minority patients, 51 enhancing its transfer to real-life settings. 52 We began with content common to both the original text and the derivative for faith communities. 53 As the instructional design was developed, we framed the common content to strengthen learning about the relationship between adverse experiences and healthcare issues, striving for cultural sensitivity to a diverse community. Next, we conducted three focus groups, two with providers and one with patients, to review and comment on the materials. Suggested changes were incorporated into the final curriculum draft.

In the second phase, we conducted a two-session pilot training at a local primary care site using the modified curriculum; 6 PCPs and 19 staff attended at least one training session. A concluding segment allowed participants to discuss content and logistics, knowledge gained, and value/usefulness to clinical practice. Further participant feedback was gathered via conference call about 10 weeks post-training. Based on the feedback, we chose a 6-hour curriculum delivered in two sessions at least one week apart, in order to give trainees the opportunity to practice new skills, and then to return and discuss their experience.

Training Content

The TI-Med curriculum focused on understanding that traumatic events may overwhelm an individual to the extent that he or she perceives threat to life, or mental or bodily integrity. The experience of trauma is seen as subjective, manifested in part by a person's inability to stay in the present, integrate feelings, and make sense of an experience. PCP training participants are taught to assume that people are doing the best that they can, that each trauma survivor has an individualized response to his or her traumatic experiences, and that behavior experienced as problematic to a provider is somehow useful to the person in adapting to the trauma experience. The training is not meant to teach universal screening for trauma, although sensitive ways to do this are discussed, nor how to identify PTSD, although PTSD is presented and discussed. Rather, it focuses on maximizing the understanding and healing power of interactions between trauma survivors and providers so that other activities like asking about trauma or symptoms, or making mental health referrals, can be done in the most trauma-informed way possible, with the best chance of trust, honesty, and follow-through.

Following the introduction of this frame, experiential exercises, such as having the group generate and define different types of trauma (e.g., interpersonal, political) and then discuss their common dimensions, helped PCPs recognize the universality of first and second hand trauma exposure, including their own. This foundation was followed with a focus on the impact of overwhelming experiences in early childhood from an attachment-informed frame, including recognition that parents and caregivers help children learn how others respond to their distress.

RC uses two core concepts to reinforce and enhance the role of relationship: the RICH ® relationship and feelings skills referred to as self-capacities. The RICH ® relationship focuses on extending Respect, Information, Connection with others, and Hope. The self-capacities, which allow the individual to maintain a consistent sense of identity and self-esteem, are managing and modulating feelings, having and calling on strong positive connections with others even in their absence (attachment), and feelings of self-worth. As participants learn and master each section of the content, they are asked to reframe and revise their responses to the main case study (i.e. a trauma patient's visit to the doctor).

Finally, the course emphasizes the role of self-awareness and self-care in mitigating the impact of vicarious trauma on the provider. Empathy, the ability to relate to and connect with patients, is grounded in self-awareness. Vicarious trauma is seen as an inevitable consequence of empathic engagement with traumatized individuals. Care of both parties - provider and patient -- is viewed as critical, with PCPs modeling respect, empowerment, collaboration, and connection.

Within the context of these principles, the training included specific content about how trauma affects people's lives - common impacts of traumatic events on body and brain, including symptoms of PTSD and depression, and broader changes, including effects on memory and perception, judgment, beliefs and worldview, and emotional skills. Studies linking trauma exposure to negative physical health outcomes were reviewed.3 Background material included aspects of child development and attachment (and how attachment can be disrupted by trauma), and the physiology of fear.

A model of the impact of trauma on relationships was presented and displayed as a poster during the training. As noted, a case of a challenging patient with trauma was presented and revisited throughout the training as each module was completed. This case illustrated training concepts, and provided the opportunity for participants to develop a deeper understanding of the manifestations of trauma, and to consider more nuanced possibilities for responding. As participants discussed the case at each phase, the trainers could demonstrate appropriate and trauma-sensitive responses. Worksheets helped the participants identify vicarious trauma as it may be affecting them in their jobs, and to make plans to address this through discussed self-care activities. Participants also received a manual that included the material in more depth, with additional readings, and a "job aid" with the realms of trauma impacts, the self-capacities, and the elements of RICH® relationships.

To strengthen the organizational response to the inevitable presence of psychological trauma in patients and vicarious traumatization in staff, nursing and support staff were invited to each training, as suggested by Glisson et al (2006) 54 and Aita et al. (2005). 55

RANDOMIZED TRIAL OF TRAINING CURRICULUM

Overview

Four primary care sites (two within Family Medicine residency programs, two in the community) were randomized into two conditions crossed with site. The primary outcome consisted of ratings from audiotapes of the PCPs interacting with standardized patients (SPs). Each condition had three clinical encounters (evaluation visits) with SPs. The immediate group had a pre-training visit, a post-training visit, and a follow-up visit, while the delayed group had two pre-visits and a post visit ( Figure 1 ). This design allowed us to make two comparisons: 1) Training to No Training (independent groups), and 2) Before Training to After Training (all participants, within subjects).

Participants were 30 PCPs recruited via site directors.

Procedure

PCPs agreed to attend training, be taped for three SP visits, and allow up to 30 of their patients to fill out self-reports. They signed informed consent, with a separate audiotaping consent. Community physicians received CME credits and all PCPs received $100.

SPs and cases were systematically assigned to PCPs so that no PCP would see the same actor, or experience the same "case" in their 3 "visits." SPs were female actors who routinely served as SPs in regional medical schools. PCPs knew that these were SP visits, and were asked to conduct the visits as if they were authentic encounters with real patients. 56 Visits were coordinated with PCP schedules, and were audiotaped. One site requested videotapes for training purposes (separate consent obtained); only the audio portion of the videotapes was used to assign ratings.

The clinical scenarios/cases comprised returning patients in a primary practice. Each PCP reviewed a "door note" before the "visit", including complaints, vital signs, and brief medical and social history. Instructions read, "Please take a focused medical history and treat/counsel the patient. Do not conduct physical examinations. You will have a maximum of 15 minutes to complete this encounter. When you conclude the encounter, please leave the room." A reminder knock was provided at 10 minutes.

IRB Approval

This study received IRB approval from Georgetown University, Howard University, Providence Hospital, and the Johns Hopkins School of Public Health.

Instruments

Development of SP Cases

Study personnel developed three SP "cases" in consultation with Dr. Roter 56 and our SP trainer, who trains SPs for Georgetown University medical students. Cases were based on common complaints in primary care, such as back pain and weight loss. Each case included a trauma history, but trauma was not a presenting complaint, reported only if the PCP asked sensitive questions. The SP's received an extensive "back story", including family, medical, social, and psychiatric history, a sample interview script and the "door note" (see above) for each case. SP training comprised 2-3 sessions, in a group or individually as needed for scheduling.

Coding of SP Visits

Audiotapes were coded with the Roter Interactional Analysis System (RIAS) 57 in Roter's lab. Raters used standard codes and were blinded to training status. RIAS categories reflect socio-emotional and task-focused elements of the medical dialogue. Codes are mutually exclusive and exhaustive. Reliability averages .85 for patient and physician categories in Roter's lab, with inter-reliability of scales with more than 4 items ranging from .76 to .81. 57 For this study, reliability ranged from .86 to 1.0 for individual items.

STATISTICAL ANALYSES AND RESULTS

Analyses

SP Ratings

We focused on a RIAS patient-centeredness composite (PCC), which incorporates a psychosocial approach and the doctor-patient partnership, to evaluate the training. The PCC score includes frequencies of doctor statements regarding psychosocial data gathering, giving information about lifestyle, education and counseling, and rapport-building/emotional, divided by number of statements about biomedical information gathering and counseling. Our primary goal was to estimate effect sizes.

The PCC underwent two types of analyses. Two-sample t-tests compared mean changes in the PCC between the experimental and delayed groups, using the 1 st to 2 nd visit scores (trained versus not trained). The average effect of the intervention was tested using a pre-post training t-test for the combined group. Differences in the PCC changes between resident and community sites were tested using two-sample t-tests and nonparametric rank tests.

Due to a technical problem, data from one PCP visit had measurement error. We imputed data for this visit using the first estimated total visit length as a function of PCPs IDs, site and visit orders (R 2=0.72). We then used total visit length as an independent variable to estimate PCC (R 2=0.92) for this visit.

Results

Participants

PCPs included 17 Family Medicine residents and 13 community providers, primarily female (70%) and Caucasian (50%), with 23% Asian and 23% African American. The most common specialty was Family Medicine (83%).

Provider Ratings

The between-group comparison on the PCC for the two groups of 15 providers ( Table 1 ) yielded a mean change score difference of 1.44 between trained and untrained groups, with the trained group improving their PPCs and the untrained group decreasing theirs, t (df, 28) = 1.76, p < .09. The associated effect size, Cohen's D, was .66, a moderate effect size. The within-group comparison of all 30 providers before to after training (see Table 2 ) showed a significant paired-t value of 3.17, df = 29, p <. 01, effect size = .61. Figure 2 shows all three points in graphic form. No differences were found by type of site (community, residency), or visit length. Notably, the higher PCC scores did not require additional visit time.

Table 1

Visit 1

Visit 2

Change
Visit 2 -1

Visit 3

Condition

n

Mean
(SD)

Mean
(SD)

Mean
(SD)

Mean
(SD)

Experimental

15

2.8 (2.0)

3.7 (2.8)

0.88 (2.64)

4.1 (2.9)

Delayed

15

3.1 (1.7)

2.5 (1.6)

−0.55 (1.76)
4.3 (2.3)

Table 2

Time

n

Mean (SD)

95% Confidence Interval

Pre-intervention

30

2.68 (1.74)

2.02

3.32

Post-intervention

30

3.99 (2.52)

3.05

4.93

DISCUSSION

Based on the PCC score, PCPs had more patient-centered interactions with SPs post-training. The training followed recommendations by CME program reviewers that training should be based on explicit theoretical frameworks and incorporate interactive and ongoing testing and practice. 58,59 This is the first test of CME training for PCPs of which we are aware with an overall focus on potential trauma issues in patients. It complements Helitzer and colleagues 39 study of didactic training in adverse events in their PCP communication training. The relative lack of training in trauma-informed care, and particularly the evaluation of such training, is a clear gap, given that trauma exposure and related mental disorders are extremely common in primary care, 9,11 and are linked with poor physical outcomes 3,16,17 and decreased preventive care. 60 Because providers are not comfortable discussing these issues, 25 the presence and influence of trauma exposure may go undetected and adversely affect a patient's ability to engage with their PCPs about their own health and care. This may reduce compliance with PCP recommendations and negotiation on issues requiring trust/engagement. This training is an opportunity to enhance the PCP-patient relationship.

Another innovative aspect was the development of standardized patient cases typical of primary care that can be used in other studies to assess training. Anecdotal feedback from PCPs suggested that these SPs came across as typical patients. While actual patient encounters may be more desirable, requiring patients to return for unneeded visits post-training was impractical. Future studies could track routine visits among trained and untrained PCPs to clarify whether TI-Med knowledge and skills are integrated into practice.

The study had several limitations. As a pilot, it used relatively small samples of PCPs. However, effect sizes for RIAS codes were moderate, findings were significant when all PCPs were combined pre- to post-training, and likely to be more significant with larger samples. All of the SP cases were women, for interchangeability of actors and homogeneity, but future studies should include SPs of both genders. PCPs and residents were primarily from Family Medicine specialties, so future studies should broaden this representation. Only short-term outcomes were addressed. A major shortcoming is that the RIAS, while an excellent system for rating patient-provider communications, is not specific to trauma. Since there are not currently robust rating tools validated for trauma, we chose the RIAS. While it is possible to add specially developed counts or ratings to the RIAS for specific studies, it was not feasible to develop new codes for this pilot. Thus, future studies need to include more trauma-specific outcomes to clarify the extent to which the training conveys concepts and skills that are trauma-related and not limited to improving general communication.

This study showed promising results for a primary care-based CME training to improve communication with trauma-exposed patients. The training increased positive aspects of the PCP-patient partnership and the residency programs welcomed it. Specialty settings may also benefit from this training. Further work needs to address the longevity of effects, impacts on interactions with actual patients, and whether and how this modest 6-hour training affects patient health outcomes.

ACKNOWLEDGEMENTS

Contributors: Interviewers Adriana Serrano, MA, Janice Yuan, Christina Parodi, PhD; SPs - Wendy Donigian (Trainer), Debbi Smith, Lynn Jane Foreman, Alice-Anna Schumacher, Lois Sanders, Sheree Allen; SITES - Family Medicine residencies Georgetown University, Pat Evans, MD, Residency Training Director, and Howard University, Ruth Elaine Graves, PhD, Dir. Behavioral Medicine, Residency Program; Spanish Catholic Center, Marguerite Duane, MD, Medical Director, Johns Hopkins Community Physicians, Gary J. Noronha MD, FACP, Director of Research; and Consultants - For use of the RIAS - Debra Roter, DrPH, Professor, and Susan Larson, MS, Senior Research Associate, Dept. of Health, Behavior, and Society, Johns Hopkins School of Public Health; and for reviewing and suggesting curriculum changes, Karen W. Saakvitne, PhD, TREATI; RA - Nicholas Talisman

Funding: This study was funded by a grant from the National Institute of Mental Health (R34 MH079970) to Bonnie L. Green.

Footnotes

Prior presentations: Portions of the manuscript content were presented as part of a symposium on New Developments for Trauma Survivors in Primary Care ( presentation entitled Improving Communication between Trauma Patients and Primary Care Providers) at the 28th annual meeting of the International Society for Traumatic Stress Studies, Los Angeles, CA, November 2012. It was also presented in a poster entitled Trauma-Informed Medical Care: A CME Training for Primary Care Providers at the 2013 MedStar Health Research Symposium in Columbia MD, March 2013.
Conflict of interest/disclosure:
Esther Giller, MA, Sidran Institute, CEO (Sidran owns the original version of Risking Connection [RC]); Elizabeth Power, MEd, EPower & Associates (EPower & Associates, Inc. is an authorized provider of Sidran's RC training and works on the development of derivative works).

REFERENCES

19. Mikuls TR, Padala PR, Sayles HR, Yu F, Michaud K, Caplan L. A prospective study of posttraumatic stress disorder (PTSD) and disease activity outcomes in U.S. veterans with rheumatoid arthiritis. Arthritis Care & Research. 2012 Epub before print. [[ PubMed] Google Scholar]

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Trauma-Informed Medical Care: A CME Communication Training for Primary Care Providers

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Fam Med. Author manuscript; available in PMC 2015 Feb 4. Published in final edited form as: Bonnie L. Green, PhD, 1 Pamela A. Saunders, PhD, 1 Elizabeth Power, MEd, 2 Priscilla Dass-Brailsford, EdD, 1 Kavitha Bhat Schelbert, MD, MS, 3 Esther Giller, MA, 4 Larry Wissow, MD, MPH, 5 Alejandra Hurtado-de-Mendoza, PhD, 1 and Mihriye Mete, PhD 6 Trauma exposure predicts mental disorders, medical morbidity, and healthcare costs.

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Trauma Informed Care in primary health settings 

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Trauma Informed Care in primary health settings 

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Trauma-Informed Care in Primary Health Settings-Which Is Even More Needed in Times of COVID-19

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Included in the general practitioner's (GP) core competencies is the ability to adopt a person-centered approach, and the use of the biopsychosocial model in their clinical work. Traumatic events (TEs) are frequently experienced within the population and are known to dysregulate the stress response system and to be associated with psychiatric and physical disorders.

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Trauma Informed Plymouth Government strategy

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Trauma Informed Plymouth Government strategy

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Trauma Informed Practice

Trauma-Informed Practice is a strengths-based approach, which seeks to understand and respond to the impact of trauma on people's lives. The approach emphasises physical, psychological, and emotional safety for everyone and aims to empower individuals to re-establish control of their lives.

Trauma-informed practice recognises the prevalence of trauma and its impact on the emotional, psychological and social wellbeing of people. Awareness of trauma has progressed over the last 20 years, incorporating knowledge from attachment, child development and cognitive memory. Frameworks of practice have changed from purely bio-medical (medicine and psychiatry) and/or purely psychoanalytical (psychology) models to include the psycho-social (trauma-informed) and a recovery focus (recovery-oriented).

In a social work context, children, young people and their family members may be living with the legacy effects of overwhelming stress (trauma). Despite the large numbers of people affected, many of us don't automatically think of the possibility that someone we meet, speak with or support may have experienced trauma. This makes us less likely to recognise it. Keeping the possibility of trauma and the sensitivities and vulnerabilities of people who may be trauma survivors in our assessment focus is therefore the first step towards trauma informed practice.

Having a basic understanding of how stress can affect an individual is important. Knowing this will make us less likely to fuel other people's stress levels. This means paying attention to 'how' we engage with other people, as well as to 'what' we do. It also means thinking about what may have happened to someone, rather than judging what is 'wrong' with them.

We should not underestimate the capacity of positive interactions, even routine interactions, to be therapeutic and validating. Positive experiences of relationships are central to trauma recovery, whilst negative experiences in relationships can exacerbate emotional and psychological impacts.

What are trauma-informed services?

Trauma often affects the way people approach potentially helpful relationships. This is because many survivors feel unsafe, lack trust or live with anxiety. Becoming trauma-informed is about supporting people to feel safe enough in their interactions with services to build trust, and to help people overcome any barriers to an effective helping relationship.

Becoming trauma-informed is not an end state, but a process. The journey to becoming a trauma-informed service can be conceptualised within 4 stages

Trauma aware: Staff understand trauma, its effects and survivor adaptations.

Trauma sensitive: The agency integrates some concepts of a trauma-informed approach into operational ethos

Trauma responsive: Individuals and the agency recognise and respond to trauma, enabling changes in behaviour and strengthening resilience and protective factors.

Trauma-informed: The culture of the whole system, including all work practices and settings reflects a trauma-informed approach.

Plymouth has recently become a Trauma Informed City, with a number of overarching objectives:

To review and reflect upon the emerging evidence regarding trauma informed approaches & Adverse Childhood Experiences, and continue to define an approach that envisions Plymouth as a Trauma Informed city.

To promote the Trauma Informed Plymouth approach (Envisioning Plymouth as a Trauma Informed City), within city communities, agencies and partnership systems.

To promote the Plymouth Trauma Lens as a consistent, universal and transformational narrative for a trauma informed city, that aspires to be courageously prevention focused.

To work alongside & support communities, agencies, and partnership systems in becoming trauma aware and trauma responsive.

To promote a system level response to the Trauma Informed approach and to support system change as a critical friend.

To target three key service areas across the partnerships, namely school exclusions, criminal justice and mental health diagnosis.

Plymouth's Trauma-Informed Network is made up of more than 70 professionals, from a number of different agencies including; Devon and Cornwall Police, city schools, Barnardos, NSPCC, Harbour, Devon CCG and Plymouth City Council, all with all with insight of how trauma can affect people. The network will start to look at a system wide approach to tackling the effects of trauma by:

preventing traumas occurring in the first place

promoting protective factors for all children

recognising the behaviours that may be the result of trauma and intervening appropriately

helping adults who are already suffering adverse consequences

Further Reading and Resources

Shemmings, D (2019) Applying Trauma Informed Work in Direct Practice, CC Inform

Young Minds (2018) Adversity and Trauma Informed Practice: A guide for professionals working on the front line

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Trauma Informed Practice | PLYMOUTH.GOV.UK

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Trauma-Informed Practice is a strengths-based approach, which seeks to understand and respond to the impact of trauma on people’s lives. The approach emphasises physical, psychological, and emotional safety for everyone and aims to empower individuals to re-establish control of their lives.

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What is trauma informed working? Innovate Project

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What is trauma informed working? Innovate Project

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Trauma-informed Practice | The Innovate Project

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We propose that services should use a ‘trauma-informed’ approach to improve outcomes across practice systems.

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Trauma-informed Practice

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Tackling Poor health outcomes - the role of trauma informed care 

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Tackling Poor health outcomes - the role of trauma informed care 

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Tackling poor health outcomes: the role of trauma-informed care

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People who have experienced trauma face a number of barriers to accessing health care. Deborah Fenney explains why a trauma-informed approach is essential for supporting a group that currently face poor health outcomes.

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There are a number of benefits to using a trauma-informed approach, not only for patients but also for providers and staff. Many patients with trauma have difficulty maintaining healthy, open relationships with a health care provider. For patients, trauma-informed care offers the opportunity to engage more fully in their health care, develop a trusting relationship with their provider, and improve long-term health outcomes. Trauma-informed care can also help reduce burnout among health care providers, potentially reducing staff turnover.

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Learn about how trauma-informed care shifts the focus from "What's wrong with you?" to "What happened to you?"

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Building on our major 2020 review of the evidence on adverse childhood experiences (ACEs), this report presents the findings of a Delphi-style consensus-building exercise to understand key stakeholders' views about the research evidence, whether it has influenced their work with children and families, and how they think the evidence can best be taken forward to inform policy and practice.

In February 2020, we published a comprehensive review of the adverse childhood experiences (ACEs) evidence entitled Adverse childhood experiences: What we know, what we don't know and what should happen next. We observed that while ACEs pose a clear threat to children's wellbeing at all points of their development, many popular claims about ACEs are not supported by the best evidence, and many ACE-related practices have yet to be rigorously evaluated. The report concluded with a set of nine recommendations about how the ACEs evidence could be improved and outlined what an evidence-informed public health response to ACEs might be.

While our review and its conclusions were positively received by a wide range of audiences, more work was needed to understand how its key messages were perceived and if they were influencing their work with families and children. To do this, we commissioned RAND Europe, a not-for-profit research institute, to conduct a Delphi-style consensus-building exercise to better understand our audience's views about the research evidence, and how they think it might best be taken forward to improve policy and practice.

Our study was successful in engaging 70 practitioners, policymakers, academics and children's charities who have a shared interest in improving children's lives. These individuals achieved consensus on 41 statements regarding the quality of the ACEs evidence and how it might best be used to help vulnerable children.

This report provides a high-level overview of the findings of this exercise, highlighting the areas where consensus was achieved and how this consensus aligns with the most robust research evidence. A more detailed analysis of our findings is also available in the technical annex.

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Adverse childhood experiences: Building consensus on what should happen next

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Building on our major 2020 review of the evidence on adverse childhood experiences (ACEs), this report presents the findings of a Delphi-style consensus-building exercise to understand key stakeholders' views about the research evidence, whether it has influenced their work with children and families, and how they think the evidence can best be taken forward to inform policy and practice.

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Trauma Informed CBT interventions for children (What works research) 

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Trauma Informed CBT interventions for children (What works research) 

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Psychotherapeutic treatments to reduce symptoms of trauma, such as depression and anxiety, in children or young people following experiences of abuse and/or neglect.

Outcome

Overall
effectiveness

This rating shows how effective the intervention is at achieving the evaluated outcome.

Click here for information about how effectiveness ratings are applied.

Strength of
evidence

This rating shows how confident we can be about a finding, based on how the research was designed and carried out.

Complex PTSD symptoms

Overall effectiveness: 1 (maximum 2)

Strength of evidence : 2 (maximum 3)

Headline points

This summary comes from the original systematic review: Leenarts, L. E., Diehle, J., Doreleijers, T. A., Jansma, E. P., & Lindauer, R. J. (2013). Evidence-based treatments for children with trauma-related psychopathology as a result of childhood maltreatment: a systematic review. European child & adolescent psychiatry, 22(5), 269-283.

This review looked at many different therapeutic interventions for children who displayed symptoms of complex post-traumatic stress disorder such as depression and anxiety following experiences of abuse and/or neglect. One intervention, trauma-focused cognitive-behavioural therapy (TF-CBT), had the largest evidence base.

TF-CBT has a low to medium positive effect in reducing the symptoms of complex PTSD for children, which means symptoms improved when the intervention was used.

However, all of the TF-CBT studies are from the USA and so we do not know how the findings relate to a UK context.

For children who had experienced sexual abuse, studies showed TF-CBT delivered 'durable improvement' in trauma symptoms. Encouraging findings were also seen in a study of children who had been exposed to domestic violence.

Use of a technique called a 'trauma narrative' produced larger improvements in symptoms and child safety skills as well as parenting skills.

All these studies included some level of parental/caregiver involvement in the intervention.

There were promising findings (but not yet enough high quality studies) for a range of other psychotherapeutic treatments which warrant further research.

Useful contacts

What is this?

This review sought to report on the effectiveness of treatments for children experiencing the symptoms of complex PTSD after exposure to abuse and/or neglect. The treatments were all psychotherapeutic and the review looked at diagnosed complex PTSD.

Complex PTSD is described by the authors as comprising 'mental health problems, such as anxiety and depression, in addition to reduced capacity for affective and interpersonal self-regulation'. MIND state that complex PTSD may be diagnosed for people who have experienced trauma at an early age or if it lasted for a long time.

Thirty-three studies were included in the review, and the authors found great diversity in the nature and quality of these studies. Therefore, it was only possible to review one treatment in depth: trauma-focused cognitive behavioural therapy. However, promising results were found for a range of other psychotherapeutic treatments including: eye movement desensitisation and reprocessing, cognitive-behavioural therapy, treatments using art, child-parent psychotherapy, the youth relationships project and systematic training for effective parenting of teens; these promising findings warrant further research.

How is it meant to work?

Trauma-focused cognitive-behavioural therapy is a well-established treatment for children and adolescents based on trauma-specific cognitive-behavioural techniques. TF-CBT includes the teaching of coping skills, relaxation techniques and psycho-education. In addition, it includes gradual exposure aimed at developing the child's management of fear and anxiety.

The review focused on effect and the authors note that there is strong theoretical evidence supporting the use of cognitive-behavioural therapy for children with trauma-related symptoms.

What are the evaluated outcomes?

How effective is it?

Overall, trauma-focused cognitive-behavioural therapy (TF-CBT) tends to show a low to medium positive effect on PTSD or PTSD symptoms, meaning that when TF-CBT is used PTSD symptoms improve. This statement is based on a moderate strength of evidence which means that there are three or more acceptable quality studies. However, the studies were not of a high enough quality to place strong confidence in the findings. Further, four of the five studies were undertaken by the developers of TF-CBT and so there is the potential for bias.

The conclusion is based on:

Five studies relating specifically to TF-CBT

Including 778 participants

Where has it been studied?

All of the trauma-focused cognitive-behavioural therapy studies included in this review were conducted in the USA. Thus, the applicability of the evidence to a UK context may be limited.

Who does it work for?

The study looked at TF-CBT for children from 3-18 years old, but the majority of children were between 8 and 15 years old. They were a mixture of males and females, 38% being male, with a mixture of ethnic backgrounds.

All studies included some level of parental/caregiver involvement. Due to the variation in the nature of parental inclusion, it is difficult to say with any certainty the most advantageous ways in which parents should be involved in these therapies.

One study looked at the effect of TF-CBT on children who have experienced sexual abuse. In a one-year follow up study, trauma-focused cognitive-behavioural therapy was shown to be superior to non-directive therapy in producing a 'durable improvement' in depressive, anxiety, sexual concern symptoms, PTSD and dissociative symptoms.

Another study looked at children who have been exposed to domestic violence. TF-CBT demonstrated a significantly larger improvement compared with child-centred therapy on measures for PTSD, depression, behaviour problems, shame and abuse-related attributions . Parents also showed improvements in depression, abuse-specific distress, support of the child and effective parenting practice.

A third study investigated the potential importance of the trauma narrative (TN) component of TF-CBT. Results showed some support for the use of TN within treatment.

When, where and how does it work?

Cognitive-behavioural therapy is widely delivered via the NHS in England for complex-PTSD.

The NHS states: 'Trauma-focused CBT is usually recommended for children and young people with PTSD. This normally involves a course of 6 to 12 sessions that have been adapted to suit the child's age, circumstances and level of development. Where appropriate, treatment includes consulting with and involving the child's family. Children who do not respond to trauma-focused CBT may be offered EMDR (eye movement desensitisation and reprocessing)'.

The length of treatment in the five studies ranged from 8-20 weeks. However, the findings showed that eight sessions of trauma-focused cognitive-behavioural therapy with a trauma narrative (TN) produced larger improvements in symptoms, child safety skills as well as parenting skills than a comparative condition without TN.

Conversely, 16-sessions of TF-CBT without TN showed greater increases in effective parenting practices and fewer externalising child behaviours than a comparative condition with TN. This may be the result of the programme dedicating more time to parenting support.

What are the costs and benefits?

No economic analysis is included in the study and cost-effectiveness is not mentioned.

How is it implemented?

Trauma-focused cognitive-behavioural therapy is delivered by a therapist. The model involves a number of core components based on trauma specific cognitive behavioural techniques. Techniques include: coping skills, relaxation techniques, stress-management, and psycho-education. These aim to modify negative thoughts and behaviours and bring about a better understanding of body safety skills, for example.

Another fundamental element of the therapy is gradual exposure, which involves confrontation of any memories or distressing thoughts of the trauma experience. This is often referred to as creating a child's 'trauma narrative' and aims to develop the child's management of fear and anxiety. This element is gradually introduced as the programme progresses. In the early sessions, initial discussions of the traumatic event or memory is kept to a minimum and avoids thoughts that may be too anxiety provoking. As the programme progresses, discussion of the events becomes more detailed and specific. This is done via methods such as drawing and writing, for example.

Parental involvement is considered integral to the process, though its nature can vary. This often includes individual sessions and joint sessions with the child and involves elements such as parenting skills support and psycho-education.

In summary...

There is a vast range of therapeutic interventions which seek to alleviate symptoms of complex PTSD in children who have experienced abuse and/or neglect.

There is a vast range of therapeutic interventions which seek to alleviate symptoms of complex PTSD in children who have experienced abuse and/or neglect.

However, it is important to stress that all five of the TF-CBT studies included in this review were conducted in the USA; thus, we do not know how these findings relate to a UK context. Also, four of the studies were conducted by the developers of TF-CBT

Some other treatments currently have promising results, but lack a sound methodological base, which means we can't yet draw conclusions about the effectiveness of these treatments, but further high quality research is warranted

Further resources

This summary comes from an original systematic review called:
Leenarts, L., Diehle, J. Doreleijers, T. A. Jansma, E. P. and Lindauer, R. J. 2012. Evidence-based treatments for children with trauma-related psychopathology as a result of childhood maltreatment: A systematic review. European Child & Adolescent Psychiatry 22(5), 269-283.

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Therapeutic interventions for children who have experienced trauma through abuse and neglect - What Works for Children's Social Care

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Vicarious Trauma Article Guardian Feb 2023 

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Vicarious Trauma Article Guardian Feb 2023 

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f I had been told that my dream career could end up affecting my mental health, I might have thought twice about pursuing it. Or perhaps I wouldn't have. After all, trauma is not new in journalism - "if it bleeds, it leads" is the adage.

But while crime and war correspondents know the risks they run, I fell into covering harrowing stories accidentally. I spent more than a decade on and off in the BBC newsroom, mostly in the user-generated content (UGC) hub team, dealing directly with the audience - finding case studies and trends, and tackling disinformation early by verifying stories before they were broadcast. Sometimes it was the best job ever, when the stories we covered could change people's lives. Other times, the job meant scouring through racist and xenophobic missives, and exposure to pornography and graphic images of human remains. I would weep and feel hopeless about the world we inhabit, as we found ourselves mapping the geographies of murder, deconstructing images of beheadings, or cross-referencing atrocities on social media videos and open-source intelligence from far-flung places.

I have always been sensitive: it is what made me good at my job. But it also made me more vulnerable

Increasingly, these tears were not isolated incidents. I couldn't switch off after my 10-hour shifts and would keep tabs on stories that I was not on rota to cover - just wanting to help if I could, finding case studies in my "real life" and sending in tips. There was no balance. I kept checking social media in case I had missed something. When trolls messaged my team's public WhatsApp number, I would reply to remind them there was a human behind that screen. I have always been sensitive: it is what made me good at the job. But it also made me more vulnerable. I lost weight because of the stress and sadness - what was the point in eating? In my head, I would keep replaying images of dead bodies, or stories of murdered children, wondering if anything could have been done.

'I found I could no longer handle the tube at rush hour.' Photograph: Jeffrey Blackler/Alamy

I found I could no longer handle the tube at rush hour. I was no longer me - the girl who liked wolves and biscuits and was capable of finding light and ridiculous things to counterbalance the sad stuff. I felt so lonely and guilty, so disappointed that the world was such a broken place, and I no longer knew what I could do to help fix it. I wanted to stop feeling so much and so empty at the same time. It was this alien experience that made me seek professional help, which is how I first heard about vicarious trauma.

...

The word trauma derives from the Greek word traumatikos, meaning pertaining to a wound, while vicarious comes from Latin, and means to substitute. But it was clinical psychologists Lisa McCann and Laurie Anne Pearlman who coined the term vicarious traumatisation in 1990, while investigating how therapists were affected by what they were exposed to in the course of their work.

Vicarious trauma usually involves a cumulative effect. It is not just one event but many things that someone is exposed to over time, which lead to a cognitive shift in the way that person interacts with the world. Symptoms differ from person to person, but can involve flashbacks, intrusive thoughts and nightmares. Those affected can feel emotionally numb or hyper-aroused; they might engage in destructive and addictive behaviours, or feel as though they have lost a sense of meaning.

While the term was initially applied to therapists, it is widely recognised that people in a range of professions can be affected. There are studies looking at vicarious trauma and PTSD in drone operators, in healthcare professionals, in social work and among social media content moderators. Legal professionals run this risk, as do people in more informal situations, such as carers.

'There are studies looking at vicarious trauma and PTSD in drone operators, in healthcare professionals, in social work, and of course, among social media content moderators.' Photograph: David Parker/Alamy

Stories about traumatised content moderators are emerging around TikTok and associated contractors globally, and in the US a class action federal court case is underway against it and parent company ByteDance. So far, the public statements issued by TikTok in response to various content moderators' allegations have focused on the company's trust and safety team and how it partners with third-party firms on the "critical work" of helping to protect the platform and community. Spokespeople have also said the company continues to develop ways to "help moderators feel supported mentally and emotionally".

In the US, Facebook (now Meta) recently agreed a $52m settlement to moderators who were diagnosed with mental health disorders, including PTSD, following a class action lawsuit led by Selena Scola. Chris Gray, who is based in Dublin, is pursuing legal action against Facebook Ireland and contractors CPL over his PTSD. He has just published an account of his experiences, The Moderator: Inside Facebook's Dirty Work in Ireland, and tells me it wasn't just the graphic imagery that affected him, but also having to deal with complaints, generally without any context, where people would report bullying or arguments playing out on the platform. "It's like 'you're a bad parent', 'you're a junkie', 'you're a slut' and then somebody's mother joins in and they are arguing about their sad, awful lives. And then somebody thinks to use the reporting tool as a weapon and they start reporting each other," he says.

Interpreters are neutral but we are not robots. Everything the person says physically goes through us

Yelena McCafferty, a Russian interpreter and translator from Lincolnshire, says her job working in public service settings with the police and in courtrooms means she often can't talk to anyone about what she hears because the material, which can range from petty theft to child abuse, is confidential. "Sometimes you just want to unburden it on to someone, but you can't," she says. She has accepted that sometimes she will have flashbacks about certain cases, adding: "Interpreters are neutral. We are there to facilitate communication, but we are not robots. Everything that the person says physically goes through us and comes out in the first person." Now, she says, there is a growing openness in her industry about the traumatic elements of the job, with training and webinars offered to raise awareness.

...

Pearlman, who is now partly retired, says her understanding and development of the concept of vicarious trauma emerged directly from her own personal experiences. Speaking to me from her home in Sarasota, Florida, she recalls a conversation one Christmas with McCann and other therapists about how she was not feeling her usual self. She knew it was not depression, but what was it? "We began to understand, in talking with our colleagues, that we were taking on the trauma experiences of our clients, and that we were feeling deeply affected in ways that changed our outlook on life and our experience of ourselves as people in the world, and also our ability to manage our feelings in a constructive way," she says.

"I was always a very trusting person," says Pearlman, "but I started to feel like questioning 'What is that guy doing over there in that park with that young girl and is that a healthy relationship?' and so on."

When even his dog started to annoy him, Murray realised something wasn't right

How permanent such a shift can be is still unknown. It is something that my BBC journalist friend Alex Murray and I often discuss. As one-time colleagues in the UGC hub, we worked on many stories together, from the Arab spring to multiple terror attacks, school shootings, beheadings, war and more. But as Murray, who at one point was deeply immersed in the reporting of jihadi movements, says: "There was a group of us who were really good at it and we were really fast. And part of our vicarious trauma was that we felt because we were good at it and fast, it was easier for us to carry the burden and get it done quickly than watch other people, who found it more difficult, struggle with it."

The work affected the two of us, but in different ways. I was afraid of the world, of building relationships, of trusting people in all aspects of my life. Murray says he stopped enjoying things that he used to find pleasurable - such as cycling - and he became irritable with his loved ones. When even his dog started to annoy him, he realised something was not right.

...

Elana Newman, a professor of psychology at the University of Tulsa, and research director for the Dart Center for Journalism and Trauma, has extensive experience of working with journalists and lawyers. She says it is important to remember that vicarious trauma can lead to positive as well as negative cognitive shifts. Practically speaking, for example: "If you work with people who were hurt in a fire, you're looking for exit signs." Or a person may become more aware of all the beauty and courage in the world around them. This is something that Murray and I understand well.

Both of us have used our experiences at the BBC to try to help others, including taking part in several studies - one a groundbreaking 2014 investigation into reporting on user-generated content, which revealed that frequency of exposure to images of graphic violence was a risk factor for psychological injuries.

And to be fair to the BBC, when some of us in the team who had been having quiet conversations with each other about our worsening moods and feelings of guilt and anger eventually raised our concerns, we were introduced to our amazing colleagues at BBC Monitoring, who had far more experience of dealing with horrific stories. They shared coping strategies with us, such as turning off audio while watching graphic material and taking time to watch joyful cartoons. However, it did take a few years for more formal protocols to be implemented, and a significant industry-wide cultural shift had to occur before our teams understood that we did not always have to be the person to watch or work on stories or videos emerging from terror attacks, natural disasters or anything that could cause additional distress. Being diagnosed with vicarious trauma was not a condition for such consideration, either. The intent was to protect people from being at risk in the first place.

'You may become more aware of all the beauty and courage in the world' ... Dhruti Shah. Photograph: Courtesy of Dhruti Shah

I first came across Sam Dubberley, a former newsroom manager at the European Broadcasting Union, when he, together with Haluk Mert Bal and Liz Griffin, was researching the effects of vicarious trauma on journalists, humanitarians and human rights workers. He is now managing director of the digital investigations lab at Human Rights Watch. He speaks regularly to his team about what they feel comfortable with investigating, and focuses on reducing the risk of vicarious trauma before it happens. He is especially concerned to include everyone who might be exposed to distressing material on a cumulative basis, such as receptionists responsible for monitoring an email address, archivists, video producers or IT support.

Newman says it is important to remember that being moved or upset by interacting with someone who is experiencing something terrible is part of "being a healthy functional person". She stresses that there is a significant difference between having an emotional response that is "adaptive, proactive and socially and morally responsible" and having a psychological disorder. But if such a disorder occurs, it is important to act. Pearlman says connection with others, and deliberately building a sense of community, can be helpful. During the pandemic, and even now, she regularly has a group of other clinicians she checks in with. Eye movement desensitisation and reprocessing (a trauma therapy for reducing distress caused by memories) and cognitive behavioural therapy can help some people.

McCafferty says she visualises a waterfall whenever she needs to build a bit of distance between herself and a case she is working on. Like me and Murray, Chris Gray has written and speaks widely about his experiences at Facebook Ireland. We have all discovered that the global community that has built up around the awareness of vicarious trauma is very welcoming.

As for me, I eventually left the BBC Newsroom to re-find that curious soul who loved sharing tales of the wild and wonderful. I know I can no longer cover certain stories, but I am hopeful about what the future will bring.

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What's it like when your job involves wading through others' suffering? I was left weeping and hopeless

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f I had been told that my dream career could end up affecting my mental health, I might have thought twice about pursuing it. Or perhaps I wouldn't have. After all, trauma is not new in journalism - "if it bleeds, it leads" is the adage.

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Women are often made to look after the emotional needs of their families, while simultaneously denying their own. Gabor Maté - who has decades of experience as a doctor working with mental illness, trauma, and addiction - says that's having a very real physical effect on our bodies by way of autoimmune diseases.

In this chat, Fearne and Gabor discuss the relationship between mental stress and physical outcomes, as well as the way in which the political systems we live in are having a huge impact on our personal mental health.

The Myth Of Normal, the book that Gabor has written with his son Daniel, is available to buy now.

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Listen to Gabor Maté from Happy Place. Women are often made to look after the emotional needs of their families, while simultaneously denying their own.

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As a therapist, you try to approach your work from a trauma-informed lens. This means that you provide a safe space where clients can trust you. You are transparent and set clear boundaries and expectations. You collaborate with your clients and empower them to use their voice and make choices.

Trauma-informed care in therapy is crucial. Most people have experienced trauma of some kind. The key in trauma-informed care is to approach each of your clients as if they have experienced trauma.

The language that you use with your clients is important. Trauma-informed language includes using words that don't trigger your clients. In fact, the word "trigger" can be triggering, for lack of a better word. It's tied to shooting a gun, and many people have been victims of gun violence.

You know this. You practice trauma-informed care and trauma-informed language all the time in therapy. But what about when you write?

It's incredibly important when writing about mental health that you use trauma-informed language. The reason is that it's not just about how you talk to your clients. It's important to use trauma-informed language when speaking with your colleagues. You also want to make sure that the language on your website and in your blogs and emails is trauma-informed.

What's the key to making sure this is the case? Hire a mental health copywriter who understands trauma-informed language and care. Better yet, hire a mental health copywriter who is also a mental health professional who has practiced trauma-informed care.

What Is Trauma-Informed Language?

By this point you've acknowledged that you need a mental health copywriter because you don't have time to write your website, blogs, newsletters, emails, and everything else that markets your business. But you want to make sure that your copywriter understands trauma-informed language.

There are a few ways to use trauma informed language in your writing:

1. Avoid aggressive and objectifying language

You know better than anyone that aggressive and objectifying language is an obvious no-no. Your trauma-informed language should make your readers feel safe, not attacked.

2. Be careful when talking about violence and abuse

When writing about difficult subjects, it's important to be careful about how you talk about violence and abuse. While these are key topics in therapy, they can be very difficult to read about and must be written with care. Don't get graphic or specific, unless absolutely necessary. And if it is necessary, write a disclaimer. It's ok to use the words "abuse" and "assault," but make sure they are handled with care. Don't go into specifics unless you have to.

3. Addressing self-harm and suicidal ideation

Self-harm and suicidal ideation are two other topics that can be difficult to write about. An important rule in dialectical behavior therapy (DBT) groups is that when talking about self-harm or suicidal ideation, you can say that you had those thoughts or that you self-harmed. You're not allowed to talk about the details. That won't always work if you're writing about these topics. But if you do write about self-harm and suicidal ideation, keep it trauma-informed. Provide resources people can use if they are feeling suicidal or contemplating self-harm.

4. Be mindful of word choice

Something else to consider when writing with trauma-informed language is the actual words you use. I mentioned the word "trigger" earlier, but there are others. Try not to tell someone to "take a stab" at something, for example. [1] Be aware of the language you use and your word choice.

5. Don't be judgmental

Another way to use trauma-informed language in your writing is not to be judgmental. Even though a blog or social media post isn't therapy, you're speaking to a vulnerable audience. You wouldn't pass judgment on your clients in session, so don't do it in your writing.

6. Avoid command statements

Trauma-informed language can also take the form of statements that provide the reader with options rather than telling them what to do. I'm currently using command statements throughout this blog because I want you to do something very specific. But if you're speaking to readers that are clients or potential clients, give them options. "If you feel comfortable..." or "when you're ready..." are great places to start.

Writing For Your Audience Using Trauma-Informed Language

Whether your audience is your clients or other mental health professionals, the same rules apply when it comes to language. If you wouldn't say it to your clients, don't say it in your writing. Clients are reading what you write, and we all know the power of the written word.

The same goes for writing for other mental health professionals. Model what trauma-informed language looks like in the written form. Be a leader in using trauma-informed language. Use social media, including LinkedIn, to set an example of how to be trauma-informed in your language.

If you know your audience, your language will reflect that. So be aware of who your readers are. If you're writing LinkedIn posts, you're probably writing to other therapists. Blogs on your website are most likely geared towards clients and potential clients, although not always. Other mental health professionals may be finding your writing and learning from you. Be a thought leader. Be a role-model in the way you speak. But trauma-informed.

Trauma-Informed Language For All

I can't stress enough that the words you use matter. Because trauma-informed care assumes that every client has experienced some sort of trauma, be aware of how you speak to them, both online and in-person.

Just as you would in your practice, make your writing a safe space for your readers. Establish trust. Build a rapport. You absolutely can do this through your writing, especially if you're using social media to connect with clients or potential clients. Actually, you can do this if you're hoping to connect with other mental health professionals, too.

Find the Right Mental Health Copywriter

An important piece to the puzzle of trauma-informed language in your writing is having the right copywriter. You want to make sure your copywriter understands what trauma-informed care and trauma-informed language is. Ideally, you hire someone like me who is also a trauma-informed therapist.

If you're ready to take the next step and talk about how I can help you, contact me to set up a free discovery call. We'll talk about how we can use trauma-informed language in your writing.

Happy writing!

Resources

[1] http://www.nationalcenterdvtraumamh.org/wp-content/uploads/2014/08/NCDVTMH-TI-Writing-Guide-FINAL-Aug27.pdf

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Why Trauma-Informed Language Is Important in Your Writing | Allie Linn Writes

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As a therapist, you try to approach your work from a trauma-informed lens. This means that you provide a safe space where clients can trust you. You are transparent and set clear boundaries and expectations. You collaborate with your clients and empower them to use their voice and make choices.