On a crisp January day, delegates were welcomed to the stunning surrounds of Wolfson College, University of Oxford by UKPTS President Professor Dominic Murphy for the Society’s annual conference, returning after a year’s hiatus as the result of our hosting duties for ESTSS2023.

Before proceedings began, Prof Murphy paid tribute to our much-missed colleagues, Prof William (Bill) Yule and Dr Hannah Murray.

This year’s theme was broad, ambitious and vital – Trauma Care: Towards an Integrated Approach – not just in respect to treatment, but also in terms of promoting a whole-person, whole-system approach to understanding and conceptualising trauma.

Conference Chair Dr Tony Downes eloquently outlined the challenge, rooting the need for an integrated approach in the historical context as well as his own professional clinical experiences. Dr Downes highlighted one of his own specific areas of interest – medically unexplained physical symptoms (MUPS) and the interplay with trauma. He drew on Gupta’s (2013) review that PTSD in particular is associated with poorly defined somatic symptoms. Understanding and appreciating this relationship he said, was crucial for those delivering primary and secondary healthcare. He reflected back on his professional experience that so much go patients’ physical health was significantly in part the result of psychological trauma, as well as epistemic injustices in health care delivery and systems.

I am having ‘pseudo seizures’- it’s all in my head. I am discharged but nobody explains what ‘pseudo’ means – I assume ‘not real’.
– Delyth Owen

Deyth Owen picked up this theme and powerfully shared her experiences of functional neurological disorder (FND) and dissociative seizures. The stunning short film, RISE introduced her profoundly impactful testimony of the damaging impact a system as a while which ‘was not set up to deal with’ people presenting with FND. “I read about hysteria and realised the stigma was very much within the health care system”, she said. “I fit into the category of the ‘hysterical woman’ perfectly, and they were able to discharge me confidently knowing this – it was a mental health problem. But the mental health team also did not know what to do with me”.

Dr Joanne Mouthaan (Leiden University, and ESTSS President) highlighted that whilst national and international evidence-based treatment guidelines for PTSD and trauma-resultant mental health problems exist, it is still an emerging field with work required to ensure trauma-informed practices are being advocated and disseminated for in occupational contexts, public health organisations, community work, schools and the wider non-trauma specialist community. Here, organisations like the ESTSS have a role to play, but more work is also required to fully understand barriers and facilitators to treatment engagement rooting the responsibility not with the individual, but with the clinician and the wider system. Integrated care needs to be collaborative, trans-disciplinary, and multi-level said Dr Mouthann whilst also paying more attention to context such as trauma histories, ongoing threat and adversity, and poverty.

In a last-minute change to the programme, Prof Murphy (Combat Stress, and King’s College London) echoed the responsibility that health care systems hold to understanding specific barriers and facilitators in order to help under-represented groups engage in research and clinical services. He focused on work by Combat Stress and its partners in using co-production methodologies to develop interventions as well as learn from user groups about how to improve accessibility to care and support. He also demonstrated how co-production with expert stakeholders and those with lived-experience has been used to identify gaps in current provision and making targeted system-level recommendations. According to Prof Murphy, ensuring you can speak the language(s) of the target audience(s) and also meet their specific needs and goals (for example policy makers, or service providers) is central to ensuring that evidence-based findings can be operationalised and lead to effective change.

We need to think about how we build services that do not just focus on the reduction of impairment, but also on the promotion of wellbeing.
– Dr Tanya Edmonds & Dr Kelly Price

Delegates enjoyed a choice of breakout sessions, held throughout the art-infused College surrounds. Drs Tanya Edmonds and Kelly Price further explored improving the health and well being of patients with FND. They highlighted that whilst disease-focused approaches provide a framework for treating the pathology illness, they cannot manage the social, psychological and emotional needs of patients with conditions such as FND. They highlighted the GENIAL model which places individuals within the context of their social and natural colonies as a starting point for promoting pathways to wellbeing from a biopsychosocial perspective.

Meanwhile, Rachel Naunton and Dr Sacha Evans highlighted that in the case of children and young people with FND, a lot of the challenges and barriers faced by adults are heightened, with added sensitivities around mental health discussions and the importance of establishing trust between practitioners and the young person. In essence, the need for centralising the child or young person in the conversation is even more important.

The dynamics of the provider-service user relationship was a particular focus for Jan Bostock who explored the Power Threat Meaning Framework (PTMF) to understand and help with trauma and adversity. At the heart of the PTMF is moving from asking ‘what is wrong with you?’ to ‘what happened to you?’, and a recognition of the social determinants and impact of power processes. Core threats on an individual ripple out to every aspect of the self, including economic and material domains, identity, social context, and emotional environment. Importantly, the PTMF recognises both positive and negative uses of power and it’s impact, and understands trauma with reference to injustices, inequalities, and environmental pressures.

[Psychedelics] allow patients to access the trauma without the fear… they can look at it from different perspectives.
– Prof Eric Vermetten

Dr Susanna Petche presented findings from the ConnectionWorks Programme – an innovative approach to treating Complex PTSD (CPTSD). The Programme involved a year of psychoeducation, lifestyle interventions and body work including yoga, Trauma and Tension Releasing Exercises (TRE), acupuncture, nature walks and equine therapy. Strikingly, outcomes included a reduction on completion in antidepressant, gastritis and insomnia medication use as well as an improvement in self-compassion measures and medical symptoms.

Innovative approaches to treatment or a different type were the subject of sessions from Liam (Nadav) Modlin, and Dr Daniel Leightley and Grace Williamson. Dr Leightley and Ms Williamson’s presented preliminary results from an innovative international study on the use of cutting-edge wearable remote measurement technologies to observe cannabis use among UK and US veterans. Whilst cannabis remains proscribed in the UK and at a federal level in the US, recreational use has been legalised in over twenty American states. Their work research not only tracks cannabis usage patterns but also explores potential therapeutic benefits (or otherwise) for PTSD symptom management.

Liam (Nadav) Modlin guided delegates through the research history and neurobiology of psychedelics and highlight common patient narratives in psychedelic therapy. Whilst similarities existed between treatments-as-usual and psychedelic therapy, Mr Modlin’s highlighted the divergences in his experiences as a psychotherapist, and in particular the therapist’s role as a supportive rather than guiding figures during sessions.

People aren’t always broken, they’re hurting.
– Dan Phillips

This point was echoed and emphasised by Professor Eric Vermetten (Leiden University) in the last of the keynote sessions. Prof Vermetten’s work with psilocybin and MDMA highlighted how the recent rejuvenation of interest psychedelic and psychedelic-assisted psychotherapy is influencing the research therapy agenda. With powerful recorded sessions excerpts, he described how psychedelic-assisted psychotherapy seemed to allow patients to participate in an ‘inner focused’ therapy, rather than being directed. Interestingly, even with exposure elements in therapy, there seemed to be an absence of fear or anxiety in comparison to more traditional exposure-based, non-assisted interventions. Psychedelics seemed to “allow patients to access the trauma without the fear… they can look at it from different perspectives” that can facilitate processing of those experiences, he said.

Dan Phillips (NHS Wales) outlined the East Flintshire Psychological Trauma Service – a trauma-informed professional community which aims to acknowledge the whole person experience of wellness. In a region where primary care is the main (or only) health care point of contact, the Service caters for a cluster of seven GP surgeries to provide multi-disciplinary expertise to treat trauma as a chronic illness, not purely a psychological disorder. Crucially, whilst serving those with PTSD, CPTSD and who have high trauma exposure, patients can also be referred who present with functional pain or MUPS. Such an integrated approach and the positive health outcomes demonstrated how important it was for practitioners to see beyond the initial presentation, and also implement trauma-informed and focused approaches at existing points of health care engagement and entry.

Rounding off Conference, Drs Victoria Williamson (King’s College London) and Brock Chisholm (Trauma Treatment International) expanded on this last point and asked delegates to consider that for those who need help the most, the practical barriers standing between them and treatment or support are often the considerable. Dr Williamson also highlighted that such barriers can cause significant moral distress for clinicians as well. Dr Chisholm expanded on the optimal conditions for trauma recovery and traumatic stress management at all levels. “The conditions and systems that so many people who are traumatised find themselves in, are completely contradictory to recovery”, he said,. In particular, he emphasised that whilst social support has been acknowledged as critical, there remain very few studies or training in how this might be promoted and amplified. They were joined by Abdulkadir Mohamed (NHS CNWL) who foregrounded the experiences of refugees and asylum seekers in particular – including his own. As with Delyth Owen’s opening presentation, he beautifully articulated the need for safety, to be listened to, and to be believed. Not only was this central to ensuring trauma care can be more integrated and better aid those who need support, but in drawing on his own story “after we help [those in need] with their social environment and structure, they can in turn contribute to society for the better”.

Finally, Dr Victoria Williamson was announced to Conference as UKPTS President-Elect. The 2025 UKPTS Annual Conference will be held in Leeds.

Selected highlights from the Conference are available on the @UKPTS Twitter feed or by searching #UKPTS2024.
UKPTS Members can download materials presented at Conference in our Member Area.

Until recently I felt slightly embarrassed about my side interest in equine-assisted psychotherapy. I feared it was just too woolly an area for someone committed to the rigorous evaluation and practice of theoretically-driven psychological therapies with clear mechanisms of change. Was my lifelong love of horses clouding my judgement? The evidence base for equine-assisted therapy for trauma is expanding and warrants exploration of the potential mechanisms at play.

Equine-assisted therapy (EAT), which also goes by other names such as equine-facilitated psychotherapy, is as yet unstandardized, and takes many different forms. Broadly, it refers to mental health professionals working with horses to help bring about psychological change for clients.¹ In practice, it often looks like a person in a field participating in exercises and games with a horse, whilst a therapist observes and provides insights and suggestions. Whilst this may conjure an image of a brave horse-whisperer wearing a cowboy hat taming an aggressive, frightened horse, the reality couldn’t look more different – the focus in EAT is on the horse as a therapeutic partne. The horses used in EAT are slow, calm, attuned. It’s more breathing and stretching than bucking and rearing, and it often does not involve riding, or require any previous experience with the animals.

The state of the evidence

There are a growing number of studies investigating the effects of EAT for people with a range of psychosocial difficulties, particularly trauma, which has been investigated both with military veterans^2-4 and young people with complex trauma histories.⁵ Most studies imply that EAT is can be beneficial to some extent, potentially resulting in improved self-esteem and quality of life, and reduced symptoms of depression, anxiety, and PTSD.^1,2  However, the evidence base is generally hindered by small sample sizes and a lack of randomization. With some exception,³ few studies go into detail about the interventions investigated and the potential mechanisms of change, making them difficult to replicate.⁶  Accordingly, there is a need and opportunity to think carefully about potential theoretical and mechanistic underpinnings, in future research and practice. Identifying and evaluating how EAT might work, and therefore who it might work best for, will be essential to building and refining the evidence base, as well as to properly investigating its claims. Here, then, are some ideas about some of the underlying mechanisms that may be at play, which I hope will both draw on and extend existing thinking on the topic.

There is no room for an elephant in the room when there is a horse.

How might it work?

Attachment: The beginning
The most common theoretical explanation for EAT is that horses, as prey animals which depend on flight as a means of survival, have evolved to be extremely responsive to subtle body language cues,⁷ not just of other horses but of humans too.  Anyone who has spent time around horses – or who has a pet dog – will agree that these animals react quickly to human posture and movements. Horses (and dogs) can provide us with comfort through difficult emotions by physical proximity (e.g. nuzzling).

However, it is not just ‘being there’ which seems to be important in this dynamic, but that the animal can move towards us in our distress – just as a responsive caregiver soothes a human infant, which, with repetition can contribute to a secure attachment relationship. This kind of stable base is also what many therapists seek to provide for their clients. When this is provided by horses as well as human therapists, it could be particularly powerful for people who have experienced trauma that affects their attachment styles. Perhaps horses are less likely to evoke the negative emotions associated with receiving care for people who have experienced trauma at the hands of human attachment figures. Experiencing interactions with an equine ‘other’ as safe and responsive could become a gateway to enabling people with attachment trauma to trust and build relationships with humans – beginning, perhaps, with the therapist.

Many people feel that their pets never judge them. Because the attunement of horse and human is played out non-verbally, the process can potentially bypass feelings of shame and guilt. Fear of judgement can be a barrier for clients with trauma histories to trust their therapist enough to talk about events for which they (often inaccurately) feel some responsibility.⁸ The German documentary Stiller Kamerad (Silent Comrade)⁹ follows military veterans with PTSD during EAT sessions. One of the soldiers had killed a man in combat, and an army paramedic talks of moral injury from not being allowed to intervene when she witnessed the kidnap of a young girl during conflict. People do not need to explain what has happened to them or what they have done to access comfort from a horse. Horses respond to embodied emotions, not beliefs or appraisals. Without a pre-frontal cortex, horses lack the new-brain competencies which enable us to worry, ruminate, and judge. Where the presence of a human therapist may be an initial barrier to progress in talking therapy, accessing non-judgemental acceptance first from a horse may give people a vital experience of relational safety that could aid the later development of a strong, trusting alliance with a human therapist.

The moment-by-moment attunement of horse with human is also reciprocal: to complete exercises such as gently asking the horse to walk by your side, you need to be attuned to the horse’s reactions. EAT may enable clients to practice responsiveness to others in a less-threatening way – perhaps for parents who can find it difficult to respond consistently to their children because of their own developmental trauma, or for people on the autistic spectrum who can find reciprocal social communication difficult.

I really did feel that maybe he’s responding to my energy.
-Participant, Hemingway et al. (2019)

Emotional co-regulation: Horses have bigger hearts?
Research has demonstrated that in humans, social processes are also conducted and reflected at a physiological level.¹⁰ Social cognition is embodied: the synchronicity of physiological processes such as breathing and heart rate indexes coordination and facilitates co-regulation between individuals.¹¹ There is some, albeit early-stage evidence that horses and humans may, in some circumstances, synchronise their heartbeats.^12,13 What this doesn’t explain is how horses can help to calm humans down, and not just mirror our threat response. One possibility is that the calming signals¹⁴ that horses use to release tension and down-regulate their own nervous systems and those of other horses are analogous to the signals used by humans. When we see a horse relax, we relax too – just as yawns echo through human groups.

What about behavioural and cognitive change? The head-heart lag reversed.
So far, I have focused on how horses may read, respond to, and down-regulate, human emotional responses. These may be potential mechanisms by which horses can facilitate emotional shifts in humans, particularly for painful emotions that can be slow to change, such as shame and guilt related to trauma. But can EAT produce behavioural and cognitive, as well as emotional, change? The head-heart lag is a popular concept among CBT therapists. This is the idea that people are often much quicker to recognise that they hold unhelpful and illogical beliefs than they are to truly feel that alternative appraisals of themselves or their problems are true – even when they readily logically accept that new ways of thinking may be more accurate.  If EAT can work at the physiological and emotional level, perhaps the opposite is true: the heart leads and the head follows. Emotional shifts can open a window of opportunity for the use of cognitive therapy techniques to facilitate new ways of thinking. Indeed, there is reason to suggest that cognitive and behavioural change can happen throughout EAT sessions.¹⁵

Watching the dance of leading and following in an EAT session could be understood through a Gestalt therapy lens. The focus given in some EAT sessions to moving and doing, coupled with an exploration of the here-and-now, resembles a behavioural intervention.  This can be combined with attentive therapist enquiry into cognitions approaching a classic CBT intervention.

It’s emotions, it’s trust, it’s responsibility.
-Participant, Hemingway et al. (2019)

As much as horses respond to humans, they are also herd animals who live in strict hierarchies and often look to people as leaders. If you haven’t experienced it for yourself, believe me when I say that the emotions aroused by being followed or not followed by a horse, ignored or pushed around, trusted or feared, can be extraordinarily powerful, and make it hard to turn away from core beliefs such as not being wanted, loved, or good enough; or familiar schemas such as abandonment, vulnerability, or seeking approval.

If one wanted to take a psychodynamic perspective, it could be said that a horse is a better tabula rasa than a human therapist could ever be – a truly blank canvas on which to project needs, desires, and beliefs, and one which doesn’t (and perhaps cannot) lie, physiologically or behaviourally. Systemic therapists (such as Claudia Swierczek who features in Silent Comrade) may see habitual relational patterns being re-enacted with an equine partner on the therapy ground, with a one-person reflecting team in the form of the human therapist always present to offer new insights on the process as it unfolds.

Certainly, the core principles of CBT are also all there: the sticky thought-feeling-behaviour-physical sensations cycle is present on the therapy ground and a responsive horse provides instant feedback to doing or feeling differently. Behavioural experiments in EAT might look like stepping out more confidently to lead the horse, or insisting on personal space boundaries, facilitating changes to negative automatic thoughts such as ‘I can’t do it’ or ‘No-one cares about me’. And horses respond quickly to both behavioural changes visible through body language, and emotions detectable as the physiological level, allowing clients to swiftly gain evidence to build new beliefs – a kind of four-legged bio-feedback monitor. Depending on the problem the client and therapist are working on, there may be an element of metaphor albeit made very physical. There is no space for an elephant in the room when there is a horse.

Grounding: Coming back down to earth.
At a basic level, horses are warm, furry, and solid, with a unique sound and smell. They are also not present in the day-to-day lives of most people in WEIRD countries. This could make horses an ideal partner for grounding and trigger discrimination in cognitive therapy for PTSD. This is evident in the opening scene of Silent Comrade, in which a siren threatens to trigger a flashback for Swierczek’s client, and she encourages him to hold fast to the horse, drinking in the horse’s corporeal solidity which signals no longer being in a danger zone. Reflecting on the session, Swierczek encourages her client to hold onto this new image of the horse when encountering future triggers. EAT may help clients to create both new mental images to counter PTSD triggers, and new experiences of safety and ways of relating pre-verbally and non-judgementally to another being. This could represent a turning point for people who find it hard to trust others enough to receive help through classic talking therapies.

Thinking traps and defence mechanisms mean nothing to horses. They respond to how you feel and what you do. Horses have a way of getting past your barriers and under your skin. With horses, there is nowhere to hide, and no-one to judge you. These twin truths, potentially both terrifying and comforting, mean that EAT may hold huge potential. To know just how much, we need to rigorously investigate empirically the mechanisms by which it may work.

Click for more details of the UKPTS 2024 Annual Conference, ‘Trauma Care: Towards an Integrated Approach’.
The one-day conference will take place on 19 January 2024 at Wolfson College, Oxford will feature speakers on a range of topics including psychedelics, resilience, functional neurological disorders and more.

References

1. Lentini JA, Knox MS. Equine-facilitated psychotherapy with children and adolescents: An update and literature review. Journal of Creativity in Mental Health. 10(3):278-305 (2015).
2. Palomar-Ciria N, Bello HJ. Equine-Assisted Therapy in Post-Traumatic-Stress Disorder: a Systematic Review and Meta-Analysis. Journal of Equine Veterinary Science. 104871 (2023).
3. Arnon S, Fisher PW, Pickover A, Lowell A, Turner JB, Hilburn A, Jacob-McVey J, Malajian BE, Farber DG, Hamilton JF, Hamilton A. Equine-assisted therapy for veterans with PTSD: Manual development and preliminary findings. Military Medicine. 185(5-6) (2020).
4. Romaniuk M, Evans J, Kidd C. Evaluation of an equine-assisted therapy program for veterans who identify as ‘wounded, injured or ill’and their partners. PloS One. 13(9) (2018).
5. Naste TM, Price M, Karol J, Martin L, Murphy K, Miguel J, Spinazzola J. Equine facilitated therapy for complex trauma (EFT-CT). Journal of Child & Adolescent Trauma. 11, 289-303 (2018).
6. O’Haire ME, Guérin NA, Kirkham AC. Animal-assisted intervention for trauma: A systematic literature review. Frontiers in Psychology.  6:1121 (2015).
7. Marchand WR. Potential Mechanisms of Action and Outcomes of Equine-Assisted Services for Veterans with a History of Trauma: A Narrative Review of the Literature. International Journal of Environmental Research and Public Health 20:6377 (2023).
8. Lee DA, Scragg P, Turner S. The role of shame and guilt in traumatic events: A clinical model of shame‐based and guilt‐based PTSD. British Journal of Medical Psychology. 74(4):451-66 (2001).
9. Stiller Kamerad. [film]. Directed by: Leonhard Hollmann. (2017).
10. Palumbo RV, Marraccini ME, Weyandt LL, Wilder-Smith O, McGee HA, Liu S, Goodwin MS. Interpersonal autonomic physiology: A systematic review of the literature. Personality and Social Psychology Review. 21(2):99-141 (2017).
11. Konvalinka I, Sebanz N, Knoblich G. The role of reciprocity in dynamic interpersonal coordination of physiological rhythms. Cognition. 230:105307 (2023).
12. Keeling LJ, Jonare L, Lanneborn L. Investigating horse–human interactions: The effect of a nervous human. The Veterinary Journal. 181(1):70-1 (2009).
13. Scopa C, Contalbrigo L, Greco A, Lanatà A, Scilingo EP, Baragli P. Emotional transfer in human–horse interaction: new perspectives on equine assisted interventions. Animals. 9(12):1030 (2019).
14. Draaisma R. Language signs and calming signals of horses: recognition and application. CRC Press. (2017).
15. Hemingway A, Carter S, Callaway A, Kavanagh E, Ellis S. An exploration of the mechanism of action of an equine-assisted intervention. Animals. 9(6):303 (2019)

Advances in Resilience Building and Psychotrauma Prevention: Towards an Integrated System of Learning and Care  – Dr Joanne Mouthaan
In the past decade, global turmoil of wars and political unrest, the surge in displaced populations and refugees and the COVID-19 pandemic have put new light on the topics of resilience building and psychotrauma prevention and their feasibility. The consistency of insecurity and the scale to which people are affected challenges us to think about what type of help can create the most effect. In this keynote Dr Mouthaan presents an overview of historical advances in the field of resilience building and psychotrauma prevention and discusses possibilities for innovation in systems of care and professional education.

PTSD, Wearable Technology and Cannabis – Dr Daniel Leightley & Grace Williamson
In this talk, we will discuss preliminary results from an innovative international study. It revolves around the application of cutting-edge remote measurement technologies to observe cannabis use among UK and US veterans. The primary focus is on understanding its effects on Post-Traumatic Stress Disorder (PTSD). This research not only tracks usage patterns but also explores potential therapeutic benefits for PTSD management. Our findings are poised to offer new perspectives in treating PTSD, promising to significantly impact veteran healthcare.

Improving the Health and Wellbeing of Patients with Functional Neurological Disorder – Dr Tanya Edmonds & Dr Kelly Price
The presentation provides an overview of Functional Neurological Disorder (FND), and explains how this condition relates to trauma and adversity. Scientific understanding of the condition and the Window of Tolerance Model is outlined, followed by discussion about the meaning of ‘wellbeing.’ The application of current theories and models of wellbeing to FND and other chronic conditions is considered. This is followed by discussion about how these models can guide intervention and service development to improve the outcomes for individuals with symptoms of FND, their families and society, as well as reducing the long-term costs of healthcare.

ConnectionWorks – An Innovative, Holistic Approach to Heal Complex PTSD – Dr Susanna Petche
We know that what is currently available on the NHS to treat those needing treatment and support with CPTSD is woefully inadequate; with vastly long waiting lists and often actually re-traumatises patients. What if there was a different way. Dr Susanna Petche a Functional Medicine GP, Trainer, Coach and expert in Psychological Trauma will share the life changing outcomes and client stories from an innovative 12-month NHS funded programme of holistic healing, treating Complex Post-Traumatic Stress Disorder. The ConnectionWorks project facilitated 32 participants through a year of psychoeducation, lifestyle interventions and body work including yoga, TRE, acupuncture, foraging walks and equine therapy, the outcomes were incredible.

Patients’ and Therapists’ Experiences of Psychedelic Therapy in PTSD – Liam (Nadav) Modlin
Amid a renewed, at times hyperbolic, interest in psychedelics as a potential treatment for mental ill health, significant gaps of knowledge remain. In the context of traumatic stress, it has been suggested that psychedelics and entactogens such as MDMA, together with forms of psychological support or psychotherapy, may help overcome the limitations of current treatment options. MDMA-assisted therapy is well tolerated in post-traumatic stress disorder (PTSD) whilst demonstrating significant reductions in symptoms. Trials have also demonstrated preliminary data for psilocybin in psychiatric disorders and healthy volunteers. At King’s College London, an early phase 2a trial assessing the safety and tolerability of psilocybin therapy in PTSD is underway.

Correspondingly, across mental health diagnoses, trauma exposure has been associated with poorer treatment outcomes, including increased likelihood of suicide attempts, self-harming behaviours, longer and more frequent hospital admissions and higher levels of prescribed medication. Further, patients with histories of physical and psychological traumas are at risk of and vulnerable to becoming distressed or re-traumatised because of healthcare experiences. Accordingly, understanding the multifaceted interactions between pharmacological and non-pharmacological elements of psychedelic therapy may be even more pertinent in patients who have been exposed to traumatic experiences.

This workshop will explore salient themes in patient and clinician experiences of psychedelic therapy for mental health indications in the context of traumatic stress. The present will discuss the research history and neurobiology of psychedelics and highlight common patient narratives in psychedelic therapy. Further, the presenter will discuss points of intersectionality and divergence between treatment-as-usual and psychedelic therapy to explore the treatment process.

Using the Power Threat Meaning Framework to Deal with Trauma and Adversity – Jan Bostock
The consideration of power influences are important for communities and individuals dealing with abuse, inequality and injustice. The Power Threat Meaning Framework (PTMF) enables us to co-develop holistic understandings of trauma and adversity that reference how power processes may be implicated in people’s experiences. I shall describe how the PTMF helps us to build on trauma informed approaches to change the dominant mental health emphasis on individual pathology. This means that we focus on people’s strengths and resources; consider with them their ideas about what has happened or is happening, and how power operates; and see their threat responses or signs of distress as strategies for survival in the light of threats they’ve experienced. Thus we can co-create meaningful and hopeful narratives that link what has happened to people with how they feel and function, and may inform organisational change.

What do you think about when you consider the feeling of shame? Stigma? Guilt? Regret? Judgment? Humiliation? These all came to mind when I asked colleagues what words they associate with shame. Shame is a powerful and pervasive experience and yet is so multi-faceted we struggled to pin down a coherent sense of what it means to experience it.

Shame can drive behaviour, influence values, and impact how and in what ways people approach the process of help-seeking as individuals, family systems, and wider communities – including my own. I grew up in a family with a complex patchwork of lived experiences where it was normal for adults to manage difficulties alone and rarely ask for help, something I had assumed was the norm. Experiences of shame run unspoken through families, individual experiences, and communities, sometimes voiced and often not.

In relation to understanding shame as a reaction to trauma, an exploration of the varying perspectives can help us develop a more integrated understanding of trauma, its consequences, and successfully treating any lasting adverse psychological effects.

The basics of shame

Broadly speaking, shame is often conceptualised as a ‘self-conscious’ emotion; a definition which interweaves notions of powerlessness, devaluation, and feeling outside of the social norm.¹ If we experience shame, we might feel unworthy of love or care. For example, we may think of ourselves as being inherently and irrevocably flawed or believe our relationships or social status are under considerable threat.²

Lee & Scragg see shame as a global attack on the self in so much that shame impacts and degrades the fabric of a person’s selfhood on multiple levels.³  This can include a negative self-identity such as ‘I don’t deserve help’, ‘I hate myself’ or ‘I will never be able change’. It can include feelings of extreme disempowerment and poor self-esteem, affective responses that erode a person’s sense of their unique identity and meaning. This can occur alongside tendencies to self-isolate and retreat from others in times of distress as opposed to turn towards others to seek help.⁴ Gilbert suggests notions of shame may have developed as an evolutionary hangover from an earlier need to prove ourselves as socially acceptable beings.⁵ Shame helped us monitor social cues, detect threat, and protect ourselves in the face of social rejection in survivalist terms.

It is important to note that shame is a related but different experience to guilt. Both shame and guilt can be biased as manufactured emotional states leading to significant pervasive distress.  However, whilst shame can be viewed as a description of significant humiliation, disgrace and dishonour relating to the self and core sense of self-worth, guilt is a description of perceived culpability and blame relating to an action.⁶

It can also be helpful to consider the interplay between shame and stigma – terms often used interchangeably in our thinking and literature. The word stigma is borrowed from the Latin stigmata which indicates a visual or physical mark of disgrace.⁷ Our common and present understanding of stigma, as such, relates to the potential for someone to be discredited or experience social devaluation. Scrambler suggests shame could be the ‘fear of encountering enacted stigma’.⁸ This is especially important when considering the effect of certain diagnoses that may themselves be related to traumatic experiences, that remain highly stigmatised both inside and outside of care environments.

Shame is a global attack on the self.
– Lee & Scragg (2001)

What is trauma-related shame?

Trauma-related shame is rooted in how a person responds to a traumatic event or series of traumatic experiences. We can think about trauma-related shame in internal terms (‘about me’), such as thoughts of ‘I should have defended myself better’ or ‘I deserved this’ or external terms (‘about others’) such as ‘others will judge me, if they know what happened’ or ‘no one will believe me if tell them’. Trauma-related shame is thought to have an eroding effect on the ‘psychological integrity’ of survivors.⁹

People can experience trauma-related shame inside and outside of the therapy room. However, we often lack a clear consensus on how to best understand and respond when we observe this phenomenon in a therapeutic context.  Traditionally, fear has been thought about as being the central emotion in PTSD.¹⁰ Significantly, there is a growing evidence base that suggests trauma-related shame is also implicated in PTSD with recent research suggesting that shame can predict symptom severity in PTSD.¹¹ However, the precise mechanisms of the relationship and potential bidirectionally between shame and PTSD and other post-traumatic sequelae is still subject to investigation.^3,12

It also worth taking a moment to consider a systemic perspective on how cultural, social and political milieus can also contribute to the internalisation of shame states and attitudes towards survivors. For example, I wonder about the impact of a survivor being asked ‘what were you wearing?’ in cases of rape or sexual assault or how dissecting and cross-examining past sexual histories or alcohol-consumption in courtrooms and across the media may impact on a survivor’s sense of self and legitimacy. How does rhetoric around ‘illegal’ migration impact upon narratives of trauma, displacement, racism, asylum-seeking, and pain?

Trauma-related shame is thought to have an eroding effect on the ‘psychological integrity’ survivors.
– Harman & Lee (2010)

Why might some people experience trauma-related shame? 

Applying a longitudinal lens may help us to take a perspective on why some adults are more prone to experiencing debilitating and chronic shame following trauma. This also relates to our theoretical understanding about why some people may be more vulnerable to developing PTSD. Lee & Scragg put forward a schematic model for understanding trauma-related shame in PTSD that draws on our earliest attachment experiences.³ We know our early experiences of receiving care impacts the way we see the world, how we view others, and how we see ourselves – these experiences are organised into schemata (akin to internal templates) that inform our expectations of the world that can be implicit or explicit.

All children need parents who are warm, caring, and attuned enough to their needs to develop a secure attachment and understanding of the world as being generally safe and positive. However, if children’s experience of early caregiving includes emotionally or physically neglectful experiences or abuse can give rise to different series of schemas or implicit perspectives that can remain dormant into adulthood. Experiencing something as overwhelming as trauma can give rise to these shame-related schemas (such as ‘other people will not help me if I ask for support’) that may maintain trauma-related shame in the aftermath of a traumatic incident. A person’s internal shame schemas might mirror the response of others (for example, the question: ‘what were you wearing?’ and associated thoughts ‘it was my fault’) or they might contrast a person’s expectations (e.g., ‘you are no way to blame, how can I help?’).

A bidirectional relationship may exist between psychological distress and trauma-related shame.
– Timblin & Hassija (2023)

The impact: clinical implications, access and potential barriers

In practice, we know people with higher levels of trauma-related shame can delay seeking help.² The media often features stories of survivors who have experienced trauma where years have elapsed before they feel safe or able to disclose. If you feel as though you do not deserve support or that people will judge you harshly or even reject you if you do reach out, it follows that you may not be able to imagine the potential benefits of disclosure (such as access to trauma support or resources). Even if you do understand the benefits, the risk-cost-benefit analysis may still land on silence as the safest option. Some research suggests shame can bias how survivors may perceive the value of disclosure following sexual or physical assaults.¹³ As practitioners, we know there is not always a case to go straight to re-processing traumatic memories or dive into hotspots and there may be value in stabilisation and grounding. However, in practice we also understand the need for disclosure; an implicit prerequisite for accessing services – especially in the NHS, where we can often ask adult survivors to disclose to a certain extent (or at least in part label or acknowledge difficulties) multiple times before therapeutic work begins – at the point of initial referral and screening, during an assessment & sometimes again at the beginning of therapy.

Even survivors who access support can be negatively influenced by experiences of trauma-related shame. Trauma-related shame can make it difficult for people to remain within what is commonly conceptualised as their ‘window of tolerance’.¹⁴ Siegal’s window of tolerance outlines the ideal state of emotional regulation that allows someone to think clearly, access feelings and memories, and engage with other people. In therapy, this looks like a client who can experience emotions while expressing difficult experiences without tipping into feeling overwhelmed or feeling nothing at all. However, when we’re stressed or feel under threat, thinking clearly can be much harder. Experiencing trauma can shrink someone’s ability to stay grounded and connected within their window of tolerance.⁹ Being outside of your window of tolerance can physiologically impact areas of the brain associated with emotion regulation and logical thinking. Instead, defence mechanisms may be more easily activated. Some of these responses may include excessive compliance, low-eye contact, intellectualisation, or an extended discussion about unrelated topics to manage or minimise uncomfortable feelings of shame. People experiencing shame-based responses may miss or cancel sessions or even drop out of treatment prematurely.¹⁵ One study found non-response rates to trauma treatment were predicted by lower perseverance, reduced ability to express feelings, and self-blame.¹⁶ Research has also suggested adults experiencing elevated shame responses may show heightened self-criticism when re-evaluating traumatic memories which may increase feelings of shame.¹⁷

Trauma-informed care involves considering what happened to a person: how they experience themselves, the world, and others through the lens of their own lived experiences in a psychologically safe and supportive way. I believe, intrinsic to this is building our awareness of trauma-related shame and developing a sensitive and collective understanding of how shame can present and interact across the whole timeline and processes of therapy, service access and engagement, as well as how we build and sustain therapeutic alliances.  Indeed, a greater and more integrated understanding of shame may also prompt us to also examine how our own relationships with colleagues, teams and services in the current social, political, and cultural milieu.

Fran Ryan is currently a trainee Clinical Psychologist at the University of Oxford. She is interested in early intervention in children and young people and is currently researching the relationship between trauma-related shame and childhood memories of warmth and safeness and self-compassion in CPTSD.  

Click for tickets and more details of the UKPTS 2024 Annual Conference, ‘Trauma Care: Towards an Integrated Approach’.
The one-day conference will take place on 19 January 2024 at Wolfson College, Oxford will feature speakers on a range of topics including psychedelics, resilience, functional neurological disorders and more.

References

1. Tangney, J. P & Dearing, R. L. Shame and Guilt. (2002).
2. Dolezal L. Shame anxiety, stigma and clinical encounters. J Eval Clin Pract. 28(5), 854-860. (2022).
3. Lee, D & Scragg, P. The role of shame and guilt in traumatic events: A clinical model of shame-based and guilt-based PTSD. Br J Med Psychol. 74(4), 451-66 (2001).
4. DeCou, C. Lynch, S. M. Weber, S., Richner, D. Mozafari, A. Huggins, H. & Perschon, B. On the Association Between Trauma-Related Shame and Symptoms of Psychopathology: A Meta-Analysis. Trauma, Violence & Abuse. 24(3), 1191-1201 (2023).
5. Gilbert, P. Evolution, Social Roles, and the Differences in Shame and Guilt. Social Research. 70(4), 1205-1230 (2003).
6. Wilson, J. P. Drozdek, B. & Turkovic, S. Post Traumatic Shame & Guilt. Trauma, Violence & Abuse. 7(2), 122-141 (2006).
7. Vanyukov, M. M. Stigmata that are desired: contradictions in addiction. Addiction Research & Theory. (advance), 1-10 (2023).
8. Scrambler, G. Re-framing Stigma: Felt and Enacted Stigma and Challenges to the Sociology of Chronic and Disabling Conditions. Soc Theory Health 2, 29–46 (2004).
9. Harman, R. & Lee, D. The Role of Shame and Self-Critical Thinking in the Development and Maintenance of Current Threat in Post-Traumatic Stress Disorder. Clin Psychol Psychother. 17, 13-24 (2010).
10. Seah, R. Dwyer, K. & Berle, D. Was it me? The Role of Attributions and Shame in Post-Traumatic Stress Disorder (PTSD): A Systematic Review. Trends in Psychology. 18(3), 675-687 (2023).
11. Matloub, J. Xiaonan, Z. Grau, P. P. & Wetterneck, C. T. Does Change in Trauma-Related Shame Predict Change in PTSD Symptomatology? Psychol Trauma. 1-12 (2023).
12. Øktedalen, T. Hagtvet, K. A. Hoffart, A.Langkaas, T. F. & Smucker, M. The Trauma Related Shame Inventory: Measuring Trauma-Related Shame Among Patients with PTSD. J Psychopathy and Behav Ass. 36(4), 600-615 (2014).
13. Timblin, H. & Hassija, C. M. How Will I Be Perceived: The Role of Trauma- Related Shame in the Relationship Between Psychological Distress and Expectations of Disclosure Among Survivors of Sexual Victimization. J Interpers Violence. 38(7-8), 5805-5823 (2023).
14. National Institute for the Clinical Application of Behavioural Science. How to Help Your Clients Understand Their Window of Tolerance. (2019)
15. Courtois, C. A. Complex Trauma, Complex Reactions: Assessment and Treatment. Psychol Trauma. 1, 86-100 (2008).
16. Brady, F. Warnock-Parkes, E., Barker, C., & Ehlers, A. Early in-session predictors of response to trauma-focused cognitive therapy for posttraumatic stress disorder. Behav Res Ther. 75, 40-47 (2015).
17. Bowyer, L. Wallis, J. & Lee, D. Developing a Compassionate Mind to Enhance Trauma-Focused CBT with an Adolescent Female: A Case Study. Behav Cogn Psychother. 42, 248-254 (2014).

Matt: I think we both have a background in working in autism services, with a lot of similarities but also some differences. Before beginning my clinical training, I worked in, and then went on to manage, a mental health care home, where we had a number of residents who had autism diagnoses. After that, I went on to work in an Adult Autism Assessment and Post Diagnostic Support team. I also have a family member who’s autistic, so I had a bit of an idea about autism before starting on this current professional path.  

Sophie: So, my experience is more child focused. I’ve previously had a year’s placement in a neurodevelopmental team, and there was a lot of work around autism diagnosis, including facilitating school observations and observing autism assessments. After that, I worked in two schools and volunteered in charities for autistic children. I have also worked in an older adult’s inpatient ward, which was helpful in advancing my understanding of trauma in particular and its presentations. Working within these settings is where I began to really notice the potential overlaps between autism and trauma.  

Matt: We realised quite quickly once we started chatting that we had similar experiences with autism, just in different settings. I think adults were a bit different because, one of the things that I hadn’t really put too much thought into was this idea of a ‘missed generation’ of autistic people.¹ So, I saw a lot of people coming for assessments who were autistic but basically didn’t realise. It was quite common for them to start to question whether they might be autistic when they became parents. Because the school might pick up on their kid being autistic, then during the developmental history part of the assessment the parent might think “oh, I used to do all this kind of stuff” or “I still do a bunch of this stuff. Maybe I want to get tested as well.” 

Sophie: That’s really interesting. I wonder if it has to do with an increased public awareness around the diagnosis. I know in the last 20 years autism diagnoses have gone up by 787%² and there’s been more funding put into autism diagnosis, especially adult services.²  Also, I guess nowadays autism is portrayed more in the media; particularly there has been a rise of talk on social media about the different presentations of autism, such as on TikTok and Instagram.  I wonder whether people might then recognise themselves, and that exposure might also create a sense of normality and acceptance.

Matt: We saw referrals to the adult service boom after the Paddy and Christine McGuinness documentary a few years ago.

The nuance and overlap [between trauma and autism] can make the diagnostic process challenging at both an individual level and in terms of services.

In my experience, lots of the interventions and techniques for autism and trauma do overlap…but there are differences.

I think the system is taking steps forward in using an integrated approach, and I hope this progress continues.

References

1. Lai, M.-C. & Baron-Cohen, S. Identifying the lost generation of adults with autism spectrum conditions. Lancet Psychiatry 2, 1013–1027 (2015).
2. Cassidy, S. A. et al. Measurement Properties of the Suicidal Behaviour Questionnaire-Revised in Autistic Adults. J. Autism Dev. Disord. 50, 3477–3488 (2020).
3. Russell, G. et al. Time trends in autism diagnosis over 20 years: a UK population‐based cohort study. J. Child Psychol. Psychiatry 63, 674–682 (2022).
4. Cassidy, S., Bradley, L., Shaw, R. & Baron-Cohen, S. Risk markers for suicidality in autistic adults. Mol. Autism 9, 42 (2018).
5. Rasmussen, P. S., Pedersen, I. K. & Pagsberg, A. K. Biographical disruption or cohesion?: How parents deal with their child’s autism diagnosis. Soc. Sci. Med. 244, 112673 (2020).
6. Moran, H. Clinical observations of the differences between children on the autism spectrum and those with attachment problems: The Coventry Grid. Good Autism Pract. GAP 11, 46–59 (2010).
7. World Health Organization (WHO). International Classification of Diseases, Eleventh Revision (ICD-11). (2019).
8. Rumball, F., Happé, F. & Grey, N. Experience of Trauma and PTSD Symptoms in Autistic Adults: Risk of PTSD Development Following DSM‐5 and Non‐DSM‐5 Traumatic Life Events. Autism Res. 13, 2122–2132 (2020).
9. Haruvi-Lamdan, N., Horesh, D. & Golan, O. PTSD and autism spectrum disorder: Co-morbidity, gaps in research, and potential shared mechanisms. Psychol. Trauma Theory Res. Pract. Policy 10, 290–299 (2018).

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).