Shifting to ‘What happened’?: Our trauma-informed approach in practice
We share practical tips on how to implement trauma informed practices into your ways of working, based on learnings from recent work by The PSC’s Transformation team.
The high prevalence of trauma in the healthcare system is becoming known and more acknowledged in recent years. Research is building a better understanding of how it impacts mental and physical health, as well as how trauma impacts the way that vulnerable individuals engage with the health system.
There is a clear case for a trauma-informed approach to engaging with these individuals illustrated in the first article of this series, where we discussed the importance of acknowledging trauma in our system and the benefits that we could expect to see from rolling out trauma-informed practices. In this article, we explore what implementing this practice actually entails.
Principles underlying trauma-informed practices
At the core of trauma-informed practice is a mindset which allows one to recognise and maintain a curious stance towards the drivers and effects of traumatic experiences. The paradigm-shift requires one to move from the question of ‘what is wrong with you’ to ‘what happened to you’?
The Office for Health Improvement & Disparities recently published a working definition and guide for trauma-informed practice, illustrating 6 key principles that guide how engagements with service users and members of the public could be conducted in a meaningful, inclusive and safe way. We reflect how we think these principles link with one another and play an important role in practice:
Principles 1 & 2: Safety & Trustworthiness
The ideal environment for engagements is one where everyone in the room feels comfortable without concerns about having a re-traumatising experience. Key ingredients to trust are a two-way relationship which is built through open communication to share experiences, and a focus on resilience and strength. We demonstrate trauma-awareness to build this trust, by explicitly acknowledging how common trauma is as an experience, and how this could impact any subsequent relationships, including the one being built in the room.
Principles 3, 4 & 5: Choice, Collaboration and Empowerment
A crucial component of trauma-informed practice is to place genuine value on staff and service user experience. Active efforts must be made to ensure their voices are heard; this could manifest through support in shared decision-making and collaboration between key organisations in the ecosystem. But most importantly, an empathetic and engaging communication style where individuals’ feelings, experiences and concerns are fully acknowledged and validated is fundamental. It’s important to bring an open-mindedness mentality to openly accept a broad range of truths and perspectives to do this effectively.
Principle 6: Cultural consideration
Given the diversity of individual experience, bringing awareness towards one’s values and moods is important, as well as the outer self through behaviours have an impact on others. In practice, it involves bringing in self-reflection and critical thinking towards yourself and others.
In the context of conducting lived experience engagements, we actively reflect on how each individual’s intersectional identity (e.g. gender, sex, race, ethnicity, class, disability) impacts the way they experience interactions with the healthcare system, including discrimination. This leads to a range of questions such as: What types of privilege will they perceive towards you? What is the resulting power dynamic in the room? Self-awareness allows us to reflect in depth about what perceptions and assumptions may be brought into the current engagement, and what we could do to level out any imbalances.
What our trauma-informed approach to lived experience engagements looks like at The PSC
The Transformation Team at The PSC has delivered numerous projects this year, placing engagements with people with lived experience at the core of our work.
Although the types of lived experience engagements have varied by piece, through a continuous learning mindset, we have developed a consistent approach across projects to ensure our engagements are trauma-informed. It largely consists of the following steps:
1. Agreeing on the remuneration policy:
As a first step, we acknowledge that remuneration is a powerful way to explicitly demonstrate that people’s time and inputs are valued. Where appropriate, we consider a range of options and feasibility of remuneration for participants with our collaborators.
2. Planning engagements:
With the overarching aims of each project and the whole end-to-end process in mind, we think about the ideal type of engagement to incorporate. Is it possible and meaningful to design ongoing engagements, bringing elements of co-production? Are one-off engagements sufficient to answer a narrower set of questions? What range of options could we offer as mediums for the engagement? Where would we encounter risks of re-traumatisation, and how could we mitigate this in the plan? With any design, the element of choice is emphasised, to make sure individuals participating have a say in how they would want to engage with us.
3. Developing and testing materials:
Following fundamental ethics principles from social research, we implement consent and safeguarding protocols to ensure safety for everyone involved in the engagement process. We consider accessibility and inclusion carefully, ensuring that engagements and written materials are designed with inclusive language and formats (e.g. by producing Easy Read materials for people with Learning Disabilities and Autism). Materials are tested proactively with our collaborators, experts by experience, and with local experts who have extensive experience of working with vulnerable individuals.
4. Identify volunteers:
We approach the recruitment process collaboratively and creatively with the local system. Where possible, we try to minimise duplication of engagements exploring similar sets of questions from any previous projects, to protect individuals from having to repeatedly revisit their difficult experiences. We often spread word on the project through existing forums and focus groups, with the aim of recruiting individuals who want to join in an organic way. Another crucial step we take is to identify key points of contact that each individual has in the system, which adds an assuring layer for safeguarding.
5. Conducting engagements:
There is a comprehensive set of practical steps we follow to ensure that the actual engagement is conducted as safely and engaging as possible. This includes organising pre-meets where needed; introducing each person in the room in depth; agreeing on any de-escalation strategies at the beginning of the conversation; clarifying the aims of the engagement, and what each person will be getting out of it; emphasising and incorporating choice throughout the engagement; and lastly having follow-up communication to express gratitude and to provide updates on how insights from engagements are being used.
We're still learning
The importance of trauma-informed practices is becoming increasingly acknowledged. However, to become fully engrained and widespread, we need to encourage these approaches to become embedded in the process of organisational change, aiming to create environments and relationships that promote recovery and prevent re-traumatisation through all facets of service design, improvement, and delivery. While system-wide efforts to implement these at policy level is crucial, we believe in the power of bottom-up change. The PSC is keen to seek opportunities where we can explore a wider range of ways to incorporate lived experience in a trauma-informed manner. We take a continuous-learning approach, striving to continually improve our methodology and lived experience offer that ultimately empowers people.
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