Psychological trauma can be caused by childhood adversities, domestic abuse, violence, and social injustice. These traumatic experiences can cause health and social problems throughout life, including mental and physical illnesses, suicide, homelessness, drug and alcohol use and incarceration. In England, nearly half of adults have experienced at least one childhood adversity such as being abused and maltreated or growing in a household with domestic abuse, parental mental health condition or substance use. Up to 29% women and 13% men have experienced domestic abuse in their lifetime,^1,2 at a cost of £14 billion a year to the UK economy.³ In healthcare services, up to 35% of patients and 31% of healthcare staff have experienced lifetime domestic abuse.⁴ Individuals and families affected by trauma seek support from healthcare and other services for the physical, psychological, and socioeconomic consequences. If the high rate of trauma and its negative impacts are not recognised, acknowledged and addressed, services can fail to engage patients in treatment and can re-traumatise both patients and staff.

A trauma-informed approach is an organisational change programme that incorporates knowledge about universal prevalence and impacts of trauma into policies and practices, creates safe environments and relationships, and promotes physical and emotional safety for all patients and staff. A trauma-informed approach starts from the assumption that every patient and member of staff have the potential of having been affected by trauma. Through realising and recognising these experiences and impact, we can respond by providing services in a trauma-informed manner to prevent re-traumatisation of patients and staff and improve experiences and outcomes for all.

The process of becoming a trauma-informed organisation is guided by the principles of safety, trust, peer support, collaboration, empowerment, and cultural sensitivity. The key assumptions and principles should be applied across the 10 implementation domains: governance and leadership, policy, physical environments, engagement of people with lived experience, cross sectoral collaboration, diagnosis and treatment for people affected by trauma, training and workforce development for all staff, progress monitoring, allocated budget, and evaluation of trauma-informed changes. It is thought that trauma-informed approaches can improve experiences and outcomes and prevent re-traumatisation in services for patients and staff. As a result, many UK policies and guidelines recommend implementing a trauma-informed approach across healthcare and other organisations. However, despite the concept existing since the early 2000s, the evidence base for its effectiveness and acceptability is still in development.

If the high rate of trauma and its impacts are not recognised, acknowledged and addressed, services can fail to engage patients and can re-traumatise both patients and staff alike.

To inform implementation of trauma-informed approaches in the UK healthcare, it is important to understand how effective they are for patients, staff, and the economy, and how they are understood and implemented locally and nationally. The TAP CARE (Trauma-informed Approaches in Primary Care and Community Mental Health Care) study is the first ever systematic review of trauma-informed organisational change programmes in adult primary care and community mental health care, including a review of UK policies. It aimed to answer:

1. How effective and cost-effective are trauma-informed organisational change programmes globally?
2. How are trauma-informed approaches represented in UK health policies?
3. How they are these approaches understood and implemented?

Our systematic review found that trauma-informed approaches are being recommended without robust evidence base, especially from UK. Despite extensive searches, we found only 6 studies (3 from the USA, one each from the UK, Australia and Canada) which evaluated 8 different models of trauma-informed approaches. None measured harms, cost-effectiveness, or staff health. Evaluations of standalone training interventions on trauma-informed care rather than a trauma-informed transformation of the whole organisation dominates the literature.

We found that healthcare organisation developed bespoke trauma-informed approaches that were tailored to their organisational needs, abilities, and preferences. The most common components included an allocated budget, a working group/committee representing all staff groups and people with lived experience, ongoing training and support for all staff, and changes in physical spaces and clinical practices.

Our policy review found that trauma-informed approaches are viewed as a potential ‘cure-all’ for tricky issues of service delivery/improvement in patient care, without being backed up by resource and commitment. Trauma-informed organisational change movement in the UK is driven from bottom-up by passionate trauma leads within organisations and local governments who self-organised in trauma-informed networks. Trauma-informed approaches in the UK has had piecemeal implementation, with a nation-wide strategy and leadership visible in Scotland and Wales and more disjointed implementation in England. Professionals wanted enhanced coordination between organisations and regions. Professionals agreed that local and national government backing is essential for implementing trauma-informed approaches at the organisation and wider system levels.

Every trauma-informed organisational change programme should have an evaluation component to generate a UK evidence base.

As a result, our key policy recommendations and considerations for the successful implementation of trauma-informed approaches in healthcare include:

• Allocating budgets and involving all staff groups and people with lived experience
• Providing ongoing training and support for all staff
• Creating safe physical and psychological environments for all patients and staff
• Evaluating trauma-informed programmes and initiatives to generate a UK evidence base
• Promoting top-down support from organisational, regional, and national leadership
• Supporting and joining local and national trauma-informed networks of professional and lived experience experts.

References

1. NHS Education for Scotland. Domestic abuse- and trauma-informed practice: companion document.
2. Office for National Statistics. Percentage of adults aged 16 to 74 years who were victims of domestic abuse in the last year, by ethnic group: year ending March 2018 to year ending March 2020, in Crime Survey for England and Wales (CSEW). 2020.
3. Rhys Oliver, B.A., Stephen Roe, Miriam Wlasny The economic and social costs of domestic abuse. 2019.
4. Dheensa, S., et al., Healthcare Professionals’ Own Experiences of Domestic Violence and Abuse: A Meta-Analysis of Prevalence and Systematic Review of Risk Markers and Consequences. Trauma Violence Abuse, 24, 1282-1299, (2023).