P&B Lecture 7 - Trauma PDF

Week 7 - 15th Nov Created @August 10, 2024 10:00 AM Tags Trauma Informed Care & Lived Experience: Reading list: PSBS0005: Current Research in Psychosis and Bipolar | University College London (talis.com) Locati...

Week 7 - 15th Nov Created @August 10, 2024 10:00 AM Tags Trauma Informed Care & Lived Experience: Reading list: PSBS0005: Current Research in Psychosis and Bipolar | University College London (talis.com) Location: Birkbeck Mallet St Room B36 Trauma Informed Care: Amy Hardy (KCL) Class Prep: Additional: Read: Pathways from Trauma to Psychotic Experiences: A Theoretically Informed Model of Post-Traumatic Stress in Psychosis Read: Trauma-Informed Mental Healthcare in the UK: What is it and How Can we Further its Development? Optional - Read: Trauma; Psychosis and Post-Traumatic Stress Disorder (Chpt 2) Key: Preparatory Lecture Psychological Trauma The Link Between Trauma & Mental Disorder 1890s → Freud linked childhood sexual abuse to later mental disorders Freud recognised childhood events can have lasting impact Week 7 - 15th Nov 1  Childhood Psychological Trauma Definition Adverse events during childhood, such as neglect, physical, sexual or emotional abuse. Though named differently throughout literature, such as “childhood maltreatment”, “adverse childhood experiences” (ACEs), “early life stress” or “developmental trauma” Risk Factor Associated with the development of psychosis, increasing the odds of experiencing psychosis by 3x (Varese, 2012) Population attributable risk for psychosis = 30% (Kirkbride, 2010) Suggesting if we could irradicate psychological trauma, we could reduce the prevalence of psychosis by 30% Not limited to psychosis → with trauma being associated with many psychiatric (Daníelsdótti, 2024) and poor physical health outcomes (Nelson, 2020) Mechanism Research suggests there may be several psychological (Bloomfield, 2021) and neurological processes (Pollok, 2022; Yang, 2023) such as Week 7 - 15th Nov 2  grey matter volume alterations in those exposed to childhood trauma Individuals with psychosis and a history of CT have higher (Aas, 2019) or blunted cortisol responses (Bloomfield, 2019) How do we know there’s a link? Bradford Hill Criteria for Medical Causation 4 Criteria, assess the evidence for each, if evidence if met = we can say there is strong evidence for a causative link between trauma and a mental health outcome (e.g. psychosis) 1. Strength and consistency of association a. CT associated with psychosis - Meta-analysis (Varese, 2012) 2. Temporality a. Trauma exposure predicts subsequent psychosis and stopping trauma reduces symptoms (Kelleher, 2013) 3. Biological Gradient (dose response effect) a. Trauma associated with more severe symptoms and poor treatment response 4. Plausible biological mechanism a. Alterations in: hypothalamic-pituitary-adrenal (HPA) axis, b. Brain alterations in threat processing and emotion regulation in limbic regions (Merritt, 2024) and dopamine transmission (Egerton, 2016; Bloomfield, 2019) Future Work Week 7 - 15th Nov 3  Need deeper knowledge of mechanisms E.g. theory of latent vulnerability (McCroy & Viding, 2015) Influence of risk and resilient factors Integrate to produce bio-psycho-social model Need development and implementation of trauma informed therapies Notes: What is Trauma Informed Care (TIC) Trauma? What is TIC? The 3 E’s Organisational approach about how a system's policies, practices, (SAMSHA, 2014) - and workforce are organised to ensure trauma-related needs are Much more broad addressed and trauma incidences are reduced. than diagnostic manual criteria re. Views trauma as ‘everybody’s business’: PTSD Realises the widespread impact of trauma Event(s) Acknowledging the commonality of traumatic events Any event Recognises trauma (trauma effects and routine enquiry) that is Recognising how that may play out in what we do in our psychologically services (e.g. how we respond to an individual lashing out or in clinic - considering the reason behind the behaviour) physically threatening Asking people about their traumatic experiences to consider any possible additional support they may Experience want Range of Responses (access to trauma-specific/focused care) cognitive, emotional, E.g. trauma-focused therapy - EMDR etc. behavioural, Resist retraumatisation physiological, and Service can also cause trauma - e.g. forced admission, restraint Week 7 - 15th Nov 4  interpersonal Organisations can amend their practices to be less reactions traumatising Effects Relation focus: Safe, trustworthy, collaborative and empowering → has a potential to be healing - relationships Range of need to be viewed in opposite dialectic to traumatic ones cognitive, emotional, behavioural, physiological, and interpersonal effects Trauma can be a precursor to psychosis, can be experienced alongside psychosis and also present as a result to psychosis. Recommendations for TIC in psychosis NHS Trauma-Informed MH Policies EIP TiC Principles: Delphi Study NICE Guidance for Schizophrenia (2014) “In EIP, assess for PTSD and other reactions to trauma because people with psychosis or Schz are likely to have experienced previous adverse events or trauma associated with the development of the psychosis or as a result of the psychosis itself. For people who show signs of post-trauma stress, follow NICE recommendations for PTSD.” Week 7 - 15th Nov 5  NICE Guidance for PTSD (2018) “Offer course of trauma-focused psychological treatment (trauma- focused CBT or EMDR), 8-12 sessions when PTSD results from a single event, extended duration of treatment beyond 12 sessions if several problems need to be addressed particularly after multiple traumatic events or other problems present.” “PTSD and complex needs (incl. complex PTSD): build in time to develop trust, take into account safety and stability of personal circumstances, identify and address barriers to therapy, plan support for after the end of therapy” Trauma-Focused CBT for Psychosis (tf-CBTp) Consistent with NICE, 2014; 2018; Hardy et al, 2020; Keen et al, 2017; van den Berg et al, 2020 Current trial - STAR (Hardy et al, 2020; van den Berg et al, 2020) Can move between phases dependant on peoples needs (e.g. doing phase 3 to help people engage in phase 2 work) Phase One: Assessment, goal setting, formulation and psychoeducation Phase Two: Trauma-focused CBT - Memory work to contextualise and elaborate memories Phase Three: CBTp - Beliefs, emotional regulation, experiences, appraisals and Week 7 - 15th Nov 6  responses CBTp = already very trauma- informed Trauma-focused therapy → focus on memory is a unique aspect. 1. True → trauma-informed organisation is designed to realise, recognise and respond to trauma, and resist retraumatisation throughout all aspects of the organisation. 2. False → trauma specific/focused treatments are delivered by people with specific trauma-focused training (curriculum of different levels of trauma-informed clinicians within the workforce) 3. True → an assumption of trauma-informed care = every interaction with a trauma survivor has the opportunity to activate a trauma response 4. False → trauma-specific/focused therapy isn’t a requirement for care to be trauma- informed 5. True → Trauma-informed care is critical for survivors but also relevant to those without a trauma history Trauma-Informed Care Implementation in UK Routine Enquiry about Trauma Requirement for all under CPA Assessed on CPA review from (“Has the abuse question been asked?”) REVA policy implementation audit in 53 trusts (Brooker et al, 2016) Found: No trusts had audited implementation Only 17% of service users were recorded as asked → ?validity (tick box exercise) Enquiry prompt does not fit with best practice guidance on conducting trauma assessments Week 7 - 15th Nov 7  Potential for retraumatisation (bring up memories that they’re not ready to address) → also a common barrier to not asking abuse question Not all individuals are aware they have experienced abuse → need to be specific in what’s being asked (e.g. if talking about physical abuse, “how you ever experienced a time where you were hit/kicked / fights, assaults, mugging etc.”) No training for NHS workforce for how to go about asking those questions → staff concerned with conducting assessments due to potential retraumatisation e.g. importance of getting informed consent prior to a trauma assessment Talking Trauma | Your Views Moving On Talking Trauma in MDTs: audit & TALE: Assessing trauma in psychosis training (Hardy et al, in prep, also see Walters et al, 2015) Found large proportion had Trauma & Life Events Checklist → made as experienced a traumatic event but existing measures assessing trauma were: only a handful of these are Too long (more interview format) followed through in terms of Or too focused on diagnostic definition assessments. of trauma Inpatients wanted routine enquiry Longer version = 20 items → if not asked, they’re less likely to share/offer out the information 20 is too long for routine MDT use Though not focused on Shortened version (mini-TALE) wanting TF-Therapy Events most likely impacting lives/MH More focus on support & V2 includes experiences of information re. relationships discrimination & functioning Week 7 - 15th Nov 8  Is Trauma-Focused Therapy Safe and Effective for PTSD in psychosis? Meta-analysis of RCTs for PTSD in Are they effective for psychosis? psychosis (Hardy & van den Berg, 2016; Meta-analysis for 12 studies (Brand et Sin & Spain, 2017; also see Swan, Keen et al, 2018) al, 2017) Small effect on delusions at both post-treatment and follow-up but only reached significance at follow-up Effects on hallucinations and negative symptoms = small and non-significant Though main target was for PTSD symptoms, not positive psychosis symptoms Conclusion: need to include Emerging evidence suggests trauma memory work in treatment in memory techniques can have beneficial psychosis impact on voices: Prolonged exposure for memories related to voices (Brand et al, 2020a, 2020b) More helpful for people with a linked trauma (e.g. reciting memories of traumatic event) Imagery rescripting memories related to voices (Palnik, Steel & Artnz, 2019, Paulnik et al, 2020) E.g. target intervention Future of TIC for Psychosis Week 7 - 15th Nov 9  Increased attention nationally and internationally Evaluation of optimal TiC approach needed Trauma-Focused Therapy for Psychosis Trials Underway: STAR. Peters et al. – Integrated tf-CBTp (26 sessions/9 months) EASE. Bentall & Varese et al. – EMDR for trauma in EI (16 sessions/6 months) Zammit et al. – EMDR for trauma in ARMS (12 sessions/12 weeks) Re.Process - van den Berg et al. - EMDR vs PE vs CR (16 sessions/13 weeks) Lived Experience Perspectives: Andrew Grundy and Tania Gergel Class Prep: Additional: Read: Experiences of Living with Mental Health Problems During the COVID-19 Pandemic in the UK: A Coproduced, Participatory Qualitative Interview Study Read: The PACT Advance Decision-Making Template: Preparing for Mental Health Act Reforms with Co-Production, Focus Groups and Consultation Key: Prep lecture - Involvement of people with relevant lived experience in research What’s the point of involving people with relevant lived experience in research? Ethics and social justice - “Nothing about us without us” Relevance - Are these the right questions and approaches? Challenge to assumptions More successful research - e.g. through better approaches to recruitment Greater impact and more effective dissemination Building Capacity Patient and Public Involvement (PPI) Week 7 - 15th Nov 10  Sometimes used as broad umbrella term for all forms of involvement, sometimes to denote more limited forms of involvement such as consultation Essential part of applying for research funding Consultations with relevant stakeholders about research questions and design, not necessarily much involvement in conducting research Participant: usually seek a representative group Often service users the relevant group — but another group may be more relevant E.g. staff, relatives, the public Service user involvement in conducting research Increasingly service users are involved in conducting and reporting on research E.g. designing data collection instruments, carrying out interviews, analysing data, writing reports Terminology Peer researchers, service user researchers, survivor researchers, lived experience researchers Training and support are key Blurred boundaries Relevant lived experience may be one of criteria in recruiting research staff; many researchers have relevant personal experience even if not the reason they were recruited Co-Production Collaborative model in which stakeholders work together throughout research process — often researchers, clinicians, service users working together Rooted in radical approach to sharing power, responsibility for decision making equally Though somewhat susceptible to being watered down in current university-based research Service User and Survivor-Led Research / Mad Studies Week 7 - 15th Nov 11  Power imbalances may be overturned, service users and survivors set the agenda if they lead research Still few large-scale studies that are led by service user/survivor researchers, involve only people with such backgrounds But increasingly advocate, and influential survivor academics with capacity to lead E.g. Diana Rose, Nev Jones, Sarah Carr, Angela Sweeney Key Related Terms Participatory Research: Research designs in which researcher hands over power to research participants - often community members Co-Design: Co-production principles applied to designing interventions and services Public engagement: the involvement of specialists listening to, developing their understanding of, and interacting with, non-specialists (HEFCE) → describes range of activities to consult and involve the public and disseminate findings to them Research Impact: The impact research goes beyond academia, including on society and the economy What could possibly go wrong? Tokenism, lack of authentic involvement, rubber stamping rather than engagement Lack of support, training and mentorship: not easy to draw on distressing personal experiences for your work Lack of appropriate reimbursement (see INVOLVE guidance) Tension between collaborating with “the system” & more radical challenge Key: Involvement of Patients and Public in Research Definition: Public involvement means research carried out 'with' or 'by' members of the public, not 'to', 'about', or 'for' them. Importance: Essential part of health/social care research Week 7 - 15th Nov 12  Improves research quality and impact Ensures research is relevant and meaningful People have a right to be involved Key Principles: 1. Involve the right people 2. Involve enough people 3. Involve people enough 4. Describe how it helps Benefits: Makes studies more relevant to participants Improves study design and acceptability Enhances participant information and communication Provides better research experience Implementation Methods: Working with research funders to prioritize research Advising on project steering groups Developing research materials Undertaking research with participants Best Practices: Start involvement early in the research process Use inclusive approaches Value all contributions Ensure meaningful influence on outcomes Organizational Commitment: Week 7 - 15th Nov 13  Many UK health organizations have signed a shared commitment to improve public involvement Includes providing guidance, policies, systems, and incentives Considerations Applies to all types of health/social care research, including COVID-19 studies Differs from public engagement (sharing information about research) Not the same as being a research participant Remember to involve patients, carers, service users, and other relevant public members throughout the research process for best results. Key: How people with relevant lived experience are involved in research Research Cycle Identifying and Prioritising Not much PPI in this area Helps to prioritise what people what researching Commissioning Following through identified topics to ensure funding and involvement of PPI Designing and Managing Often happens before project starts Managing can be done via an advisory group with PPI involvement & ensure protocol is followed Undertaking Doing review, analysis and writing up findings Can include PPI via advertising research posts requesting lived experience Disseminating Often difficult with PPI Implementing Week 7 - 15th Nov 14  Translating what was found in the research to real-life Evaluating Impact Important to produce evidence that PPI works Often retrospective but more useful to make evaluation a continued reflection throughout the process Top Tips Involvement as early as possible Establish and maintain a patient and public reference group Establish relationships with patient groups/charities Finding patients/public People in Research (website) Clinical Research Network Asking community Network Advertising in GP surgeries, outpatient departments, local newspapers and on the radio Talking to local or national patient support groups and voluntary organisations Researching online for relevant organisations Using social media Talking to other health and social care professionals → e.g. community development workers, social workers, health visitors, GP practice managers Accessibility Jargon free Acronyms Times Distance Disability Week 7 - 15th Nov 15  Resource patient and public involvement Payment policy Expenses Build into research proposal Quick and slick Training and support Training in research More than one patient/public Nominated liaison person Feedback Acknowledgement Respect expertise of the patient/public Hierarchies of knowledge Training Regular communication Managing Expectations Topic Location Description of organisation Experience Description of work Time Payment Expenses Support/training Influence Week 7 - 15th Nov 16  Notes: Coproduction-bringing lived experience perspective into mental health research ⚠️ Aspiration - coproduction in mental health can: Improve quality / impact of research Challenge stigma & disempowerment Improvement and Coproduction → practical difficulties: Limited Developmental Stage Awkward Issues Resources: No money typically Tokenism (e.g. tick-box / leaving it Money available during this stage too late) Time How are people with lived Vulnerability assumption experience paid? The assumption that they’re Training inherently more vulnerable “cognitive and Most with lived experience psychologically” haven’t received any training in research Identity Expenses Lived experience researcher? Prioritisation within research Validation of input Week 7 - 15th Nov 17  As opposed to a tick box Hierarchy (‘managed democracy’) How is it maintained Should have equal status and throughout the research? opinions equally considered Accommodating illness Representativeness Mental Health and Justice - Impact Log “Service User Advisory Group - SUAG” How did the SUAG contribution impact on your research? “The contribution from the SUAG directly informed study protocols and helped with ethics application. The input from the SUAG about the risk/benefit balance of making advance decision making documents helped respond to concerns from clinicians who might otherwise have been less willing to take part in the project” “I have also presented this paper to groups of academics and would like to point out that in addition to being the most engaged group I have discussed it with, and the group that tied it most directly to the real experiences of people with mental disabilities, the SUAG easily showed the most insightful analysis of weak points in the paper.” Impact Log Combined Coding Brain and Genomics Hub From research ‘participants’ or ‘cohort’ to research ‘community’ Week 7 - 15th Nov 18  Brain and Genomics coproduction strategy Expand LE leadership Expand inclusivity/representation Expand scope Assess impact Expand the concept of ‘expertise through experience’ Advance Choice Documents Thinking ahead in mental health - Using your past to plan your future What are Advance Choice Documents? Advance Choice Documents (ACDs) are written or spoken records that allow people with fluctuating mental illness to say in advance, when they are well, what treatment they would like should they become ill. They provide key information for family, friends and professionals who might treat them if they become unwell. If you are considering an Advance Choice Document, you might provide information about things like your illness, treatments which work/don’t work and contact details both for family/friends and for health professionals who are familiar with your history. There are lots of different names for Advance Choice Documents – you might also hear them called ‘Mental Health Advance Statements, ‘Advance Choice Directives’, ‘Psychiatric Advance Directives’ or ‘Advance Care/Crisis Plans’. To see all these terms and their explanations, visit our ‘Jargon explained’ page here. An Advance Choice Document is not a legally binding document – but it can provide important details and guidance, especially for healthcare professionals who are unfamiliar with you and how to care for you when unwell. When are they relevant? Advance Choice Documents are relevant for people who have had an episode or episodes of severe mental illness, and who have valuable experience about their illness and how best to Week 7 - 15th Nov 19  treat it. They are written when a person is well, and come into action when that person becomes unwell. Week 7 - 15th Nov 20