Trauma Informed Care for Psychosis PDF

**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 **Childhood Psychological Trauma** **Definition** Adv...

**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 **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 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)* - Strength and consistency of association 1. CT associated with psychosis - Meta-analysis *(Varese, 2012)* - Temporality 2. Trauma exposure predicts subsequent psychosis and stopping trauma reduces symptoms *(Kelleher, 2013)* - Biological Gradient (dose response effect) 3. Trauma associated with more severe symptoms and poor treatment response - Plausible biological mechanism 4. Alterations in: hypothalamic-pituitary-adrenal (HPA) axis, 5. Brain alterations in threat processing and emotion regulation in limbic regions *(Merritt, 2024)* and dopamine transmission *(Egerton, 2016; Bloomfield, 2019)* **Future Work** - Need deeper knowledge of mechanisms 1. 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?** **The 3 E's** (*SAMSHA, 2014*) - *Much more broad than diagnostic manual criteria re. PTSD* - **Event**(s) - Any event that is psychologically or physically threatening - **Experience** - Range of cognitive, emotional, behavioural, physiological, and interpersonal reactions - **Effects** - Range of 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.* **Trauma Informed Care (TIC)** **What is TIC?** Organisational approach about how a system\'s policies, practices, and workforce are organised to ensure trauma-related needs are addressed and trauma incidences are reduced. Views trauma as 'everybody's business': - **Realises** the widespread impact of trauma - Acknowledging the commonality of traumatic events - **Recognises** trauma (trauma effects and routine enquiry) - Recognising how that may play out in what we do in our services (e.g. how we respond to an individual lashing out in clinic - considering the reason behind the behaviour) - Asking people about their traumatic experiences to consider any possible additional support they may want - **Responses** (access to trauma-specific/focused care) - E.g. trauma-focused therapy - *EMDR etc.* - **Resist** retraumatisation - Service can also cause trauma - e.g. forced admission, restraint - Organisations can amend their practices to be less traumatising - **Relation** focus: Safe, trustworthy, collaborative and empowering → has a potential to be healing - relationships need to be viewed in opposite dialectic to traumatic ones **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." **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 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 - 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 & training \*(\**Hardy et al, in prep, also see Walters et al, 2015)* - Found large proportion had experienced a traumatic event but only a handful of these are followed through in terms of assessments. - Inpatients wanted routine enquiry → if not asked, they're less likely to share/offer out the information - Though not focused on wanting TF-Therapy - More focus on support & information re. relationships & functioning **TALE: Assessing trauma in psychosis** - Trauma & Life Events Checklist → made as existing measures assessing trauma were: - Too long (more interview format) - Or too focused on diagnostic definition of trauma - Longer version = 20 items - 20 is too long for routine MDT use - Shortened version (mini-TALE) - Events most likely impacting lives/MH - V2 includes experiences of discrimination **Is Trauma-Focused Therapy Safe and Effective for PTSD in psychosis?** *Meta-analysis of RCTs for PTSD in psychosis (Hardy & van den Berg, 2016; Sin & Spain, 2017; also see Swan, Keen et al, 2017)* Conclusion: need to include memory work in treatment in psychosis **Are they effective for psychosis?** - Meta-analysis for 12 studies *(Brand et al, 2018)* - 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 - Emerging evidence suggests trauma memory techniques can have beneficial 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** - 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)