Can Do Healthcare - Thinking Differently Together About Trauma Informed Care

Suffolk and North East Essex Integrated Care System (ICS) 1. Start With Why? Online event Wednesday 27 October 2021 ‘Thinking Differently Together’ about… Trauma Informed Practice Introduction: Reconstructing trauma across our system Many of us will have heard the terms trauma, trauma informed care, trauma informed practice, and adverse childhood experiences (ACEs), and these are all now topics that are currently in our consciousness and being talked about, with increasing importance, across the system. It has always been important, but it has come to the forefront and we are talking a lot more about it now, and putting it at the forefront of our practice, our planning and our strategic approach, as we are recognising the prevalence of trauma in our communities more than we ever have done before. As someone who delivers service related to trauma, Fiona explained how she had recognised a change from a few years ago, when there was little interest in trauma, and it didn’t fit succinctly with anyone’s service. Now there is interest, maybe as a result of the collective experience of living through the pandemic and the various ways it has affected all of us. We are now recognising that trauma happens to so many of us in so many different ways. As a system, it is up to us to ensure we are prepared to do something about this if it isn’t to be just a set of buzz words that disappear after a small flourish and some training. Trauma informed still needs a succinct, accurate and universally accepted definition as a term. However, there are three principles that need to underpin it: • An awareness of the prevalence of trauma in our community, patients or cohort • An understanding of the impact of trauma on physical, emotional, and mental health, behaviours and how people engage with services • An understanding that current systems and that way in which we work, can and often does, retraumatise the individuals being treated, supported and cared about, albeit in unintended ways. A trauma informed organisation or service is one where everybody in it recognises that trauma is not necessarily a single event but is an organising experience which shapes both individual relationships in it and organisational service cultures and responses, regardless of what they are. Trauma informed organisations will conduct all of their relationships, processes and practices in light of this fundamental understanding. ACES include experiences in childhood such as physical and emotional abuse, neglect, parental mental illness and violence in the household. The theory of ACEs Fiona Ellis, Chief Executive, Survivors in Transition 1 | Suffolk and North East Essex Integrated Care System

is that the more ACEs you experience as a child, the more likely you are to develop things like heart disease, diabetes, poor academic outcomes, and substance misuse. Whilst the ACEs model can give us early indicators, we must exercise caution about how and where it is used and what the context is so it is used in a balanced way, because much of the current narrative ignores the limitation of the evidence base from which it comes, and not everyone who has an ACE score will live out the ‘predictors’ such as being in prison or having an early death, and ‘dooms’ them to a certain life or pathway. The model can fail to recognise scales of resilience in those who experience trauma. Trauma is a huge subject: it elicits such different emotions in all of us. It can be most simply defined as any experience we have had that has overwhelmed our ability to cope - whether it happened today, yesterday or thirty years ago. There is no scale or benchmark to trauma, and maybe as a system that is what we struggle to cope with. The sheer volume of variables that trauma encompasses challenges our system in its current set-up. The core experiences of psychological trauma are disempowerment and disconnection – when deconstructed, trauma plays havoc with systems of care, protection and meaning that support in our communities and it is the harder option to exercise. For most people who have experienced trauma it remains largely unresolved: it tends to be deconstructed and is pathologised into individual symptoms, because currently, that is how our system is set up to work – it’s no one's fault, it is just the way that it has always been, but that doesn’t mean it has to be the way that it is always going to be. We know loads more now about how trauma impacts us physically, mentally, and emotionally, but our system breaks things up into manageable symptoms like PTSD, anxiety, depression, eating disorders, substance misuse, disordered personalities, behaviours etc. Unfortunately, this means that the preferred approach is a sticking plaster approach, which isn’t effective or efficient and certainly doesn’t have the trauma survivor at the core of it. It often means that trauma survivors get caught in a revolving door of many, many services and have to tell their stories in the context of whichever service they are coming into contact with. Trauma is pervasive, and it finds parts of us as humans to live in, that sometimes we didn’t know we had. This can be lived out through physical pain, unexplained illnesses, emotional pain, distress, self-harm, guilt, shame, dissociation, and grief, to name but a few. Every symptom of trauma has a purpose. Every symptom is a piece of a bigger puzzle – these symptoms contain intelligence and are telling us the story – the whole story, not just the bits we are comfortable with hearing. At the moment we are treating symptoms as problems, rather than purposes or insights across our system, and this needs to change. We have come to place such an emphasis on the traumatic event itself that we have forgotten to look at the impact that it has had on an individual, and individual responses and reactions, including their inbuilt resilience and strength are often discounted as solutions. To reconstruct trauma in our system and for our service users and communities we could validate and recognise its pervasive nature across our communities. • The World Mental Health Survey Consortium reports that over 70% of adults have reported a traumatic event since the age of 18; 30% of those have been exposed to four or more traumatic events in their adult life – at least 20% of those will go on to develop PTSD as a result (N.B. this doesn’t take into account childhood trauma). • We know that 7.5% of our population have experienced sexual abuse before the age of 18, and that 20% of women and 4% of men have experienced some type of sexual assault since the aged of 16. Thinking Differently Together | 2

• In the year ending 2019, 1.6 million women experienced domestic abuse in the UK, and every year, 1 in 3 victims of domestic abuse are men, equating to over 750,000 men every year. • Just under 40% of people involved in road accidents in the UK, develop PTSD as a result. • 1 in 8 individuals in our UK armed forces have been seen in military healthcare for a mental health related reason. • People who suffer and survive critical illnesses are at significant risk of developing PTSD. • Up to 45% of new mothers report experiencing birth trauma. If we add to that list those who experience traumatic injuries, victims of crime, hate, bereavement, loss, natural disaster we start to see the picture that it is an enormous amount in our communities that are affected by trauma. Effective trauma treatment isn’t about telling stories of what happened in the past, it’s about what is happening for people now, it’s about helping people to be present and to tolerate and manage what they are feeling in the here and now. Seeing symptoms as intelligence and insight into trauma experiences and recognising normal reactions to abnormal events will ensure that trauma is dealt with more effectively and differently within our system. Recognising resilience and working with people to utilise their resilience helps to reconstruct and recontextualise trauma in a way that is more manageable for the individual, rather than what is more manageable for the system. This can be done by starting to see beyond ‘what is wrong with you’ and start seeing ‘what happened to you’ when we are dealing with individuals in our services and roles. An effective recovery process requires the reconstruction of these symptoms and systems. Trauma informed care or practice would look different in every setting because it is based on unique individuals and their organisations - whether it is used as a culture shift, a framework or even as a lens through which services can be reviewed, commitment must be made to the following principles: • It has to be a whole system approach – it is not something we can do in a siloed nature, which is what up to now, has happened. It is essential that we adopt the approach across our whole system to prevent it just being another buzz word for the year, or just a twohour training session that people did. The way in which people heal and engage with our services will not change unless we make some changes as a whole system. • Trauma awareness - trauma informed practitioners will understand that not only the prevalence, but the impact of trauma amongst their service user cohort, and within their own workforce. Policy and practice within organisations and systems will reflect this awareness. • Trauma informed systems have to be strengths based – service users and practitioners will work together, identifying focus on existing strengths and resilience and building upon those. • Genuine choice, empowerment and restoration of relationships will be part of trauma informed service delivery for both service users and our workforce, to facilitate healing and avoid re-traumatisation. • Trauma informed practice or care cannot exist without safety. Policy and practice at every level will reflect our commitment to provide both physical and emotional safety for service users and staff across our whole system. Fiona finished with a call to action: highlighting how, for this to work, it is important for all of us no matter what our role in the system is. People are telling us very firmly and clearly what they need from us and we must listen differently. Trauma and our response to trauma is firmly on the agenda in our ICS and it is up to us all to keep it there. 3 | Suffolk and North East Essex Integrated Care System

Lived Experience - Afrika’s Story “How do I tell people what had happened to me? How do I tell people that I’ve been sexually abused? – well I don’t. It’s something that I’ve had to carry for most of my life so it’s something I don’t feel the need to bring up. The only time I do is when my vulnerability starts to come out; so for instance, if I’m having something like a smear test, that feels very invasive to me, so I will give a healthcare professional the heads up then, but I often feel that they look at me kind of strange because I don’t think they can see the correlation between sexual abuse and something like a smear test, which is obviously quite routine for most women, but there is a direct correlation – so yes, it’s navigating things like that. With a smear test you obviously have different sized speculums: If someone who has been sexually abused hasn’t had a lot of sexual experiences because of that, why do they not have the virgin speculums? That is something that, when I’ve asked, they say we don’t actually have them – so you’re in pain and that’s a big problem, it’s a big deal. I’ve had much support over the years for it, I mean, everybody at Survivors in Transition has helped me and I even had therapy when I was young, and I’m continuing to have support for that – It was something that I’ll need to top up, it’s not something that I’ll just get over. What’s important when I am able to say what’s happened to me and I need that support, in whatever capacity, is empathy. Sometimes I’ll say in my situation how difficult it is and I know the words are being heard but they’re not really being listened to, and the healthcare professional isn’t being very accommodating – they’re just like ‘ok, but we’re still going to go on’ . I think from a healthcare point of view, what could be done better is for GP practices, they need to know that they are not the gatekeepers and they need to be better at signposting; they need to know that there are other provisions that are doing equally, if not more important work in the community and they need to have better ties. Also they need to look at mental health as being as important as physical health". Lived Experience - Steve’s Story “I served for 25 years in the London Fire Brigade as a frontline firefighter and during that time I experienced lots of traumatic incidents – fatal incidents, road traffic accidents, fires, suicides, quite a lot of suicide, and over a period of time that sort of builds up, and not one incident, but all of them become traumatic. Just taking a broad average, a firefighter who is operational might see four of five fatal incidents in a year, sometimes less. There was one particular year when I experienced ten fatal incidents in the space of a month, and that had a major impact on me, to the extent when I would go to sleep, and couldn’t sleep, couldn’t shut my eyes because all I kept seeing was these dead people. Every time we went out on a shout after that, I kept thinking I was going to see more death, more fatalities. Something happened at work that had a bad effect on me and I just felt like I couldn’t go to work anymore and I went to see my GP, and the GP prescribed me anti-depressants and a course of counselling through the NHS. I went to the counselling session and they were lots of sympathy – I got lots of sympathy but that’s not really what you need: So, after a period of time I went back to work, and I still wasn’t right. I approached the Fire Brigade counselling team and they were very good because they specialised in that sort of trauma and they understood everything that I was talking about, so rather than just give me sympathy they actually gave me solutions. Two years’ worth of counselling I had, and it didn’t really change anything, and then they recommended Eye Movement Desensitisation Reprogramming (EMDR) therapy, and that is to drag put all the stuff that you’ve pushed to the back of your mind. I did that for about six months, once a week every week and some of the stuff that came out just surprised me because I’d long forgotten about it – or thought I had, and the effect that it had on me when they came out, it was just like being back there and experiencing it again, only this time, instead of pushing it to the back of your mind you’re dealing with it. My advice to healthcare professionals would be to get as much training as you can, but relevant training, and to specialise. So no matter who comes forward for help, the mental health team could assign someone that is actually experienced with that type of problem – that would be a lot more useful to the person who has come forward for help”. Thinking Differently Together | 4

From Hidden Harm to ACEs to Trauma Informed Approaches Sharon reflected back, how in 2008 she joined Suffolk County Council as a Young People’s Substance Misuse Commissioner, having come from a nursing and health improvement background. In starting to explore what this new role meant she rapidly became aware of two reports: In 2003, the UK Advisory Council on the Misuse of Drugs published ‘Hidden Harm’, the product of an inquiry that exposed the “problems” of parental drug misuse on their children and their families, and how professionals struggle to respond effectively. In 2007 there was a follow up and the UK Advisory Council on the Misuse of Drugs published ‘Hidden Harm Three Years On: realities, challenges and opportunities.’ This report suggested that, despite the report three years earlier, there was still an awful lot to do to improve outcomes for these families. In response to this, in 2008 the National Treatment Agency began a push for Drug and Alcohol Action Teams to benchmark themselves against the recommendations in the Hidden Harm Reports and develop partnership action plans to address shortfalls. Sharon explained how, in doing this work she developed a huge passion for what the evidence was showing on how a difference could be made – and understanding the linkage between poor parental mental health, domestic abuse and drug and alcohol misuse within a family. This was becoming often referred to as the ‘Toxic Trio’. Knowing that this toxic trio equally has its roots in hardship, poverty, lack of income, lack of employment, unstable housing, and then goes on to perpetuate those hardships, and that for children growing up under these circumstances, there is a risk of growing up to perpetuate the same difficulties for themselves and for any children they may have – giving rise to an intergenerational cycle of negative consequences. The Toxic Trio is now more commonly called the ‘trio of vulnerabilities.’ A multi-agency, Hidden Harms Steering Group was established that was both an operational and strategic partnership of like-minded enthusiasts who wanted to improve outcomes for children and families. Their work was prioritised by the Local Safeguarding Children’s Board and the Children’s Trust in their Children and Young Peoples’ Plan, with a strategy and actions that were reported on and evaluated. As a result, there was a lot of work on raising awareness, with both policy and service development being impacted, along with improved partnerships and collaborations and a lot of interest being generated in the work. Fundamentally important is the notion that just because a person has experienced such adverse childhood experiences , doesn’t mean that they are going to have a detrimental impact going forward – there are protective factors, and it is those that we really need to enhance, promote and put into place. "Just because kids are growing up in what we consider adverse circumstances – it doesn’t mean that they can't succeed. Parents and other caregivers who are supportive have a lot of power to be buffers, so building the skills and capabilities of all caregivers is a big deal – ensuring that they have the skills they need to provide a stable, responsive environment for children." Tassy Warren, Centre on the Developing Child, Harvard University 2. Understanding the story Sharon Jarrett - Head of Health Improvement (Children, young people and families) and risk behaviours, Suffolk Public Health Domestic Abuse Substance Misuse Mental Health Toxic Trio 5 | Suffolk and North East Essex Integrated Care System

The group ran until 2017, and as its momentum began to wane, the science of Adverse Childhood Experiences (ACEs) came into greater focus. Studies had been taking place in the late 1990s that looked at the correlation between adverse childhood experiences, and the long-term impact into adulthood on the physical and mental health of the children and families who experienced the repeated trauma associated with such factors. Most importantly, the children and young people that experienced them, have a greater risk of impaired development, impacting on their ability to learn, their cognitive development, emotional regulation, ability to socialise, have good relationships and be able to behave in a way that conformed. The results of this could be seen across our system. The CDC-Kaiser ACE Study, conducted between 1995-1997, was the first to examine the relationship between early childhood adversity and negative lifelong health effects. This and other studies found that the long-term impact of ACEs determined future health risks, chronic disease, and premature death. Individuals who had experienced multiple ACEs also faced higher risks of depression, addiction, obesity, attempted suicide, mental health disorders, and other health concerns. ACEs Childhood abuse: • Verbal abuse • Physical abuse • Sexual abuse • Neglect And households which included: • Parental separation • Drug misuse • Alcohol abuse • Domestic abuse • Parental incarceration • Poor parental mental health Yet ACEs are not inevitable, nor do they have to determine the destiny of a child who experiences them. ACEs can be prevented, and when they do occur, concrete steps can be taken to help children heal. Healthy parent-child relationships, or other supportive relationships, can serve as a protective buffer, and help children foster resilience and thrive. The neuro-science underpinning ACEs takes away any possible predisposition to blame of parents and carers, and it can help us as service-providers be kinder to ourselves, each other and those we are trying to help. Experiencing the stress of this constantly repeated trauma or major trauma during our development, or at any stage in our lives, can have long lasting effect and impair our emotional regulation, distort our perception of how we are received and our ability to socially and familially engage and nurture; how we learn and find meaning, and at worst, pre-dispose us to perpetuating some of those negative factors. So – where are now: We have a core multi-agency strategic group for ACEs, including those with lived experience, with a strategy, an action plan and an associated web based large Community of Interest, providing a quarterly newsletter and information and resources. We are developing a series of webinars on ACEs and trauma informed approaches that will form a programme of awareness raising and learning, available at any time for professionals to access virtually. Training and awareness-raising initiatives are being developed in collaboration with CCGs and Suffolk County Council drawing on evidence-based models such as Signs of Safety. This includes a pilot programme of workforce training on ACEs and Trauma Informed Care, which will be delivered by Survivors in Transition. Trauma informed approaches are now being embedded across Suffolk County Council’s children’s and education services, and mental health services are developing further, giving us a good foundation to learn from and build on. Looking forward. Recent evidence reviews and reports from the Early Intervention Foundation advocate further research into ACES and trauma informed approaches to build the evidence base of what works and recommend adopting a Public Health Approach of whole system action from prevention, early intervention to mitigate risk and specialist intervention to aid recovery when consequences are already being experienced. You can read the full report here: Adverse childhood experiences: Building consensus on what should happen next | Early Intervention Foundation (eif.org.uk) Thinking Differently Together | 6

Jessica explained that she works in a team that complete specialist assessments of, and direct work with children and families, as well as bespoke parenting where families have most likely than not had trauma experiences. Many of the families, children and adults that the team at the Family Centre work with will disguise their traumatic experiences, generally as a defence mechanism and a way to keep themselves safe, which make it hard for practitioners, particularly those dealing with crisis response trying to manage the balance of immediate risk and being mindful of who is behind the person. Being trauma informed doesn’t mean stopping this work ethic, it means being more aware and curious about what is being managed and why it might be happening and as social workers, becoming more curious about who is the person behind the presenting behaviour. It’s not ‘what is wrong with you’ but ‘what has happened to you’ “Don’t take a fence down until you know why it was put up” - Dr Karen Treisman, (2017). One of the things being looked at and to be conscious of, are the thoughts, feelings and actions around the behaviour, and along with that comes the emotions: Emotions are really difficult for parents and for survivors to talk about. Jessica spoke about a piece of research she had looked at recently, regarding talking about the painful events and that it doesn’t necessarily establish community – often quite the contrary. Families and communities may reject members who ‘air dirty laundry’, friends and family can lose patience with the people who get stuck in their grief or their hurt, and this is one of the reasons why trauma survivors often withdraw, and why their stories become rote narratives, edited into a form least likely to provoke rejection or concern. Jessica reflected how one of the families she had worked with recently; a Mum who had a fear within the child protection arena that if she shared that her emotional protection as becoming too overwhelming, it would cause concern for the children to escalate, yet if she didn’t share it they would escalate for her inside her anyway, to the point where there would be need for a crisis response, such as calling for an ambulance or attempting to take her own life. Either way she was always in fear of her safety and the safety of the children. When working with children and families and becoming more trauma-informed, one of the things noticeable is that we can see beyond the initial presentation of behaviours. Jessica referenced further metaphors created within Karen Treisman’s work (2017) ‘sometimes it is better to attack than be attacked; sometime it’s better to be scary than be scared and sometimes it is better to be feared than to be fearful’ – and these are useful in recognising why someone may be presenting in a certain way. This awareness helps in recognising there is a need to look underneath that and understand what is going on for the person. Being trauma informed practitioners requires social workers and other professionals to be curious and creative within their approach. It requires them to look beyond the label or the behaviour and recognise the thoughts and the feelings of the individual, to determine what is contributing toward their action. Jessica explained how often with children and families she works with, when she is exploring with them their experiences, childhoods, where they have come from and what shapes who they are today, generally that in itself can be very triggering. It is therefore vital for social workers and all professionals to be confident in not just dealing with trauma, but also dealing with how to support children and families they are working with around regulating those emotions. Quite often what we are inevitably doing is asking families to provide the information we as practitioners need to be able to 3. Being trauma informed with families Jessica Tye, Social Worker, Clacton Family Centre, Essex County Council 7 | Suffolk and North East Essex Integrated Care System

provide support, but they are then left with all the emotions they have supressed for so long. Jessica shared how she has been further investigating and researching self-regulation activities. She gave an example of how she had worked with a Mum where they considered different smells, and lavender was a smell she associated well with, so they would have lavender in the room when she came in so the room smelt of it, to build an association with a soothing and calm feeling, which helped her to concentrate when she came into the room, and think about things in a more relaxing environment. They also created some spray bottles of lavender scent that she took home with her to spray on her pillow, and although she knew that that smell was something she could associate well with, it wasn’t necessarily something she would have done by herself, and this was something we could use to help her acknowledge the emotion, that helped her then take it away. An example with children is of a young lad who had experienced significant trauma, whose concentration within sessions would be minimal, so they would employ the use of a variety of different fidget toys and gadgets that he could use within the room to help regulate his emotion. He seemed to quite like hanging onto and holding tight to a goal post when they played football, and what he often found was that when he let go, he felt more relaxed and regulated. When he was in school, what helped was talking to the teachers and staff about what he could do when he was playing football with friends, such as stretching up in the sky as tall as he could and then letting the stretch go and shaking it all off. Becoming more trauma informed and becoming confident in that in working with children and families, to help support them with mechanisms to regulate their emotions and reduce how ‘triggered’ they feel when they leave sessions, is vital. Essex County Council’s Children’s Social Care has developed strategic groups to look at how teams and professionals who have completed the training, and have a continued interest in the work, are promoting the practice within their teams and how they can support their colleagues to become confident social workers when dealing with trauma. Lived Experience - Jane’s Story “I was sexually abused by my father and also his friend. I suffered severe abuse as a child, and I suffered abuse again with a man for 20 years who is the same age as my father. I have been diagnosed complex Post Traumatic Stress Disorder (PTSD) and a few other things that I can’t remember. I have a very bad memory, a very selective memory and it has been my coping mechanism, and sadly a lot of survivors don’t remember – it’s the worst thing, because if you don’t remember you don’t want to say anything to anyone, so no one really knew anything. I’ve had help for domestic violence, I have help for childhood sexual abuse but not a lot of help. I was with that man and it was self-help, so my own tools, and writing. I don’t know what I write but it means it comes out, so I don’t carry it. Healthcare professionals need to think about how they approach a person who is the victim of trauma, and in what manner. I think they definitely need to say, after the person has spoken, they need to tell them to go and sit somewhere and calm down. That’s very important, it’s very traumatic to be talking about these kinds of things. I was told to go and lie down, and I didn’t, and I walked straight into a bus lane – I regressed to the state of a toddler and walked straight into a bus lane, and if my partner hadn’t been there I probably would have died, because I just wanted to get out; so I would say to the healthcare staff that the person must calm themselves down because it’s very, very difficult. It gets easier the more you talk about it, but the first time you just really need kid gloves.” Thinking Differently Together | 8

4. How we can make a difference… Psychological interventions – Trauma Falling Out of our NHS Staff Diane explained how her role covers multiple aspects; as well as being the Associate Director of Nursing for NSFT, she is the lead for trauma informed care, the lead for the staff covid support service, the internal trauma therapy service for staff, and also veteran’s mental health. She is also currently mobilising a model called Trauma Risk Incident Management (TRIM) across the Trust. Diane has also developed an international Trauma Informed Care Network, which now has now been running for a year and has in excess of 250 members. Diane told us about a project she has been involved with that was developed in response to the pandemic, as staff have been under immense pressure – being redeployed to areas they are not familiar with, working excessive hours, making difficult clinical decisions and dealing with distress, fear and bereavement. First and foremost, our workforce are human beings who also have their own lived experience, and the pandemic has brought to the service many existing and past traumas and compounded them. They have set up an NHS England funded staff Covid support service which is open to all health, social care and care sector staff across Norfolk and Suffolk. Staff can self-refer or make contact via Suffolk Mind to access the dedicated clinical hub. Within the hub they can have full choice over the background and gender of the therapist they would see, and whether their appointment is face to face, online or via telephone. Following an assessment, they are then given rapid access to trauma focused therapy – whilst counselling can be useful in validating emotions, offering compassion and empathy, it doesn’t get to the root cause of the challenges, unlike NICE guideline, trauma focussed interventions like EMDR, trauma focused CBT, cognitive processing therapies. As the workforce can be fearful of coming forward, confidentiality was a big issue for them, so the recording system is completely separate, ensuring that their records cannot be accessed by any of their peers or managers. The service has now supported 212 staff, and in response to setting up that Covid support service, the NSFT Executive Board identified the need to look at their own staff generally, who are witnessing suicide, serious self-harm or may be the victims of physical or sexual assault within the workplace, and what was being done for them. A dedicated trauma therapy service for NSFT staff called ‘Support for You’ was rapidly mobilised. They have now had 107 staff treated through that service. They are now in the process of mobilising TRiM, with a dedicated group of TRiM practitioners and mangers across Norfolk and Suffolk, as a peer led initiative to ensure that all staff get a rapid response and debrief for any traumatic incidents. Trauma is universal – all staff have the potential to come with trauma: We need to validate that experience and we have to be careful that when we are talking about those who are expert by experience and with lived experience because there are two cohorts of staff – those who will disclose their past trauma and those who don’t. There are the people that feel if they tell you how bad they feel they will be at a disadvantage – fearful that they may lose their nursing or social work registration, or be viewed differently in the workplace; and if they don’t tell you they will internally suffer – without help they will personally implode and be unable to care for themselves or others. The turnaround time for staff to access the service is 1-2 days for an assessment and 2-3 weeks for therapy; Diane Palmer, Associate Director of Nursing, Norfolk and Suffolk NHS Foundation Trust (NSFT) 9 | Suffolk and North East Essex Integrated Care System

including a comprehensive stabilisation and therapy programme. Taking care of the staff who are caring for staff, works through having reflective practice sessions and clinical supervision, and time to talk which is non-work related that is just to give unit cohesion and helps build resilience within the teams: By taking care of each other we are equipped to take care of other people. People who have lived experience often also experience post traumatic growth, which is important to focus on amidst the doom and gloom. If we support and intervene the cycles following terrible events can be broken, and people can go on to thrive post trauma, and we need to look at that recovery focused approach. Lived Experience – James’ Story “It started with the neglect and the physical abuse from my Mother – my real mother. I used to wet the bed where I was so nervous, and I used to get beaten so much, and my Mum never used to change it, so I would have to sleep on a wet bed every night. Obviously I went to school smelling of urine, so I used to get bullied a lot, so that is sort of where it started. I had to bring myself up because my Mum was neglecting me, and then the sexual abuse, where I was left to wander the streets late at night, at 5, 6, 7 years old – the house would be locked so I couldn’t get in the house, so I just had to occupy myself, feed myself, clothe myself and do everything myself, I found a way. That made me feel very alone, very isolated and also I had a lot of hatred inside me, a lot of anger and a lot of issues; not realising how badly that was affecting me on a daily basis. I reached out to the mental health team, and luckily enough I was able to become stabilised on medication; it slows my brain down and helps me process information a lot easier. It was the beginning of last year that I started talking to a guy called Ged, and that was where my journey started with Survivors in Transition. It’s very important for people to get the help they need: Its nice to have someone to listen to you for starters, after, for so many years, your voice falling on deaf ears and being dismissed. Just the fact that you can actually talk to a human being and they actually listen to you, you know, they’re listening and they’re interested in what you’ve got to say. Just for me that was a first, because my Mum and my Dad were never there, so I never had anyone to listen to me and to take on board what I was saying. I think that started to instill some self-confidence back in me and I started to actually feel like a person again. People are out there – there are kind people out there; there are nice people you can trust, because trust is another big issue, you know. Obviously, going through what you do as a child it’s hard to actually trust someone after being let down so many times. Thinking Differently Together | 10

Warren opened by telling us that while he knows nothing about Shakespeare - as English was not one of the two O levels, he left school with - he does know that when Shakespeare spoke about the slings and arrows of outrageous fortune e.g. where you were born; the circumstances you grow up in; the assets that are around you; and the people that are around you, these are not things you generally have any control over, but you’ve got to find a way of coping and of being able to go forward with your life and find a way. Resilience is how we deal with the slings and arrows of outrageous fortune. Sometimes with resilience comes a notion that it is all about the individual and what resides in them: Whilst there is some truth in the physical body, mind and relationships we have being things that can help us, it is also bound up in the community and the circumstances that we live in, grow up in and the time that we are born in. Davies AR, Grey CNB, Homolova L, Bellis MA (2019). Resilience: Understanding the interdependence between individuals and communities. Cardiff: Public Health Wales NHS Trust. 5. Resilience - a few useful ideas for living and working with adversity and trauma Dr Warren Larkin, Consultant Clinical Psychologist and visiting professor at the University of Sunderland 11 | Suffolk and North East Essex Integrated Care System

Our opportunities to cope, to thrive and reach our potential are to some extent determined by the community capitals, the assets, the people, the places, the access to opportunity and resources, those things are important in terms of whether someone can thrive and reach their potential. It is not all about trying harder – resilience isn’t simply about trying hard and being tough and being gritty, it’s about finding a way of adapting and moving forward no matter what your circumstances are. If you look on the internet the things that will come up are: • ‘The capacity to recover quickly from difficulties; toughness…’ • ‘The ability of a substance or object to spring back into shape; elasticity’ (Oxford English Dictionary) • Resilience is “the process of adapting well in the face of adversity, trauma, tragedy, threats or even significant sources of stress.” (American Psychological Association, 2014) Whilst the first point is off the mark, the second is a little better, it is the third point that describes it fairly well. Human beings are not at the top of the food chain because they are the fastest or the strongest or because we have the biggest teeth – but we are adaptable, and we are social creatures – that’s why we are so successful as a species. Resilience really is about adaptation, about resources, and a combination of biological, psychological, social and cultural and spiritual factors that interact with one another to determine how a person reacts to stressful life events. They can change over time and according to context. There are some important things that happen in our lives in infancy – developmental things in childhood that are really useful in helping us have a happy and successful life, but many other things can be acquired. Resilience also changes over time, so you might be someone with a PhD, a high status job, good pay and a stable social life, and then suddenly war breaks out in your country and you have to flee, finding yourself leaving everything with just the clothes on your back. Your ability to be resilient and your ability to cope is going to change, even though you were doing so brilliantly in this other circumstance. Resilience has to be curated – it’s not stable, it’s not static and the recipe for resilience changes according to time and place, and each individual. Resilience and adversity are a bit like the two sides of a scale: On one side are positive assets and on the other are stresses, or what the Harvard Centre for Child Development refer to as toxic levels of stress. The foundations of health in life are in Maslow’s hierarchy of needs – a safe place to live; food and water; a loving environment; a stable attachment with a caregiver is really helpful. If you have a caregiver who is attuned, who is able to help you emotionally develop, is able to co-regulate and respond to you when you are distressed and help your nervous system calm down and relax and develop that control over your stress response – this is called selfregulation, and you can only develop it through co-regulation (having an attuned care giver). These things give you a really strong foundation of resilience. If you haven’t had those things, that’s alright, you can still develop coping strategies, resources, assets and relationships and cope really well, but those things do have an impact on how difficult you find the social Thinking Differently Together | 12

world, manage your emotions and how hard it is to manage your emotional life and social life. It’s really important therefore, that we focus on the early years and good parenting, because these things are preventative. Public Health Wales did a study of 2500 people to investigate people with high levels of adversity - four or more adverse childhood experiences – to look at what were the things that predicted being well, and what were the things that might lead to people developing mental health issues. They found that people that reported high levels of childhood resilience factors – the main ones that stood out being having a trusted adult relationship and regular sports participation – people that reported those things were about half as likely to have a current mental illness. When asking about adult resilience factors they similarly found, people that reported high adult resilience factors were about half as likely to have a current mental health problem. Important factors were not being poor and having to deal with poverty every day, and a degree of community engagement and feeling like a part of something and that they have others around them that they could rely on. A recent study from the US looked at the factors that predict mental health in adult life and positive relational health that asked respondents to score how often as a child they: (1) felt able to talk to their family about feelings; (2) felt their family stood by them during difficult times; (3) enjoyed participating in community traditions; (4) felt a sense of belonging in high school (not including those who did not attend school or were home schooled); (5) felt supported by friends; (6) had at least 2 non-parent adults who took genuine interest in them; and (7) felt safe and protected by an adult in their home. They found there was a dose response relationship with positive mental health and positive relational health. This study gives proof that these are all things that need to be encouraged and supported. A programme of ACE screening has been introduced in California. Although Warren wouldn’t recommend introducing screening in the UK at present, he articulated that he would Source: Hughes, K, et al (2018), full report available here 13 | Suffolk and North East Essex Integrated Care System

strongly recommend asking people what has happened to them, if they are seeking help. We need to ask people what happened to them, give them a caring and compassionate response and see what kind of help people might want or need. The programme in California takes a public health approach and offers people a ‘menu’ of activities that can help them stay well, rather than giving a treatment response or referral to specialist services. These can counteract the consequences of a sensitised stress response, the wear and tear on the immune system, the inability to self-regulate, difficulties in relationships, and offer people support in holistic ways. Warren reflected that we have known for millennia that it is relationships that heal and make a difference, and compassion makes a difference in care. In psycho-social interventions it is the quality of the relationship that consistently predicts outcome – not solely the technical abilities of the person, their years of experience or the type of therapy. We have to make sure it is possible for there to be a quality relationship between the worker and the person they are trying to help, and we have to look after the people that look after people. If our workers have nothing ‘in the tank’ they will have little to offer people from a compassion and relationship perspective. Joblink Plus is fundamentally an organisation that supports people into employment, but they have also developed particular expertise and experience in supporting individuals, families and communities affected by social and economic exclusion, racism and trauma. They have chosen to become trauma informed in what they do. Whilst employment can be beneficial and the relationships in employment can play an important role in recovery in some circumstances, employment may also be a source of trauma. Therefore, in seeking to support people into employment there is a need to be mindful of what is a separate debate around bullying and gaslighting in which some individuals have become badly traumatised by their experience of work. Research tell us that both previous and ongoing trauma are very common in job seekers whose struggle to gain employment may have been prolonged or interrupted. It is often a combination of factors that are causal but when we look at ACE statistics such as unemployment rates, we see that there is a rate of 62% among those with 4 ACEs and no academic qualifications. There are therefore some very particular groups who are at risk of longterm unemployment with the social and economic exclusion that it involves, and with the exposure to 6. Working with Individuals Not in Employment Education or Training (NEET) in a Trauma Informed Way Dr Brodie Patterson, Director Joblink Plus, Tamworth (New South Wales, Australia) Thinking Differently Together | 14

poverty then acting as a further source of trauma. Not having a trauma informed approach, as currently is seen in relation to long term unemployment in most of the UK, where it is viewed as being a consequence of motivational deficits or people of bad character making bad choices, re-creates the dynamic around the abuse of power which may have been the original source of harm. Using sanctions that threaten shame and potentially starvation, compound rather than address the issues the individuals already have. Effective intervention needs a very different narrative and approach. The literature tells us that if we can create a relationship based around respect, trust and empowerment we can successfully support people into education, training and employment and the benefits of connection, structure, purpose, self-esteem and hope that it can bring to people and transform their lives. To do this we need to adopt an approach that says relationships are key. We need to focus on how we provide services in ways which acknowledge what has happened to individuals and promote relationships with job seekers of respect, warmth, psychological and cultural safety and dignity that empower people. If we don’t, we may trigger, resurface and reactivate feelings of mistrust stemming from previous experiences and preventing us establishing the trust we need to underpin collaboration. To do this we need to think about how we train and enable staff to engage with people. We need to think about the core themes of trauma informed practice in choice, empowerment and respect that creates a place of safety for individuals. JobLink Plus have integrated clinical services within the employment support service. They employ a number of clinical staff who, as part of access to employment support, may offer support around the issues of sleep, anxiety, or addiction. One of the things Joblink has found in doing so is that it engages with population who might, in the past, have been described as ‘hard to reach’ by services. The emerging narrative from these individuals is a powerful, and eloquently expressed one - that it is not that these individuals are hard to reach, it’s that services have been hard to reach for them – they haven’t persisted, they haven’t used a relationship-based model, they haven’t worked with people respectfully, they haven’t provided opportunities for choice. These individuals have accessed services but opted out because of these factors. If we take a trauma informed approach and create an integrated service that looks at the individuals strengths and needs and treats them holistically and respectfully it works. If we don’t do that feelings and the power imbalance are resurfaced and reactivated, and this prevents the trust needed to support people successfully, from being established. A major take-away message is that it is connections that make the difference. In any setting, if we can make people feel that their value and worth are recognised, it enables them to experience a sense of safety and wellbeing where they can grow and flourish. If we can create positive and safe connections and sustain those connections over time, and Joblink have worked with some individuals over a number of years and though a number of crisis we can achieve success. If we don’t do that and revert back to that default approach around sanctions and shame and victim blaming, we simply damage people further – we do not help them on their journey and that is not good enough. We have to understand and respond to the root causes of unemployment for some and pursue approaches that enjoy psycho-political validity. JobLink have also been successful in looking at support for parents, at programmes around gender, and in working with communities to address some of the root cause issues. They work extensively with indigenous communities, and the literature on the health and wellbeing of indigenous communities in Australia is startling. Undoing the harm caused by racism and economic and social exclusion will take generations, but if we start form a position of respect and we start from a position of connection, we are in a good place to start undoing that harm, one person, one family and one community at a time. Fundamentally trauma informed practice in any context is about collaboration and engaging with root causes: If we can do that successfully then we can work more effectively and help undo some of the harm. In our efforts we need to recognise resilience and celebrate post-traumatic growth. Trauma does not necessarily just leave people scarred; it sometimes also leaves people stronger – they are survivors not victims. When we remember that and can engage those strengths in working with individuals respectfully we can create new opportunities and new hope. 15 | Suffolk and North East Essex Integrated Care System

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