Why trauma-informed practice is needed more than ever in Scotland

The recent revelations from Forth Valley Royal Hospital of the death of a vulnerable young man from alleged over-sedation have shocked many and led to calls by the Lib Dem health spokesperson for “an immediate and comprehensive investigation”. The facility appears to have deep-seated problems, according to a whistleblower’s allegations. They include a refusal to admit people in crisis due to their mental health diagnosis, their drug use or being viewed as “for prison”, resulting in the individuals ending their own lives. But with a wider culture in Scottish mental health services of a medical model dominant approach to care, these events are perhaps not as shocking as they first appear.

The medical model approach to mental illness

The medical model of mental illness locates the problem solely in the individual or their family history, and centres around their biological, physiological and genetic makeup, rather than considering external factors such as environment, events in their life history, or social and economic circumstances. It therefore focuses on medication as the default initial treatment rather than including alternatives such as psychotherapy to help improve the situation the person finds themselves in. Inevitably when prescribed drugs do not seem to ‘work’, a dose may be increased instead of incorporating other ways of addressing the problem. Overreliance on medication in Scotland increases the risk of overdose and over-sedation which inevitably increases the risk of fatalities.

The medical model also centres the blame squarely within the individual, while at the same time potentially stigmatises and pathologizes them. As a consequence, their thoughts and behaviours can be seen as manifestations of their disorder and their uniqueness as a human being is lost. So, when certain diagnoses are associated with certain symptoms, the testimony of the individual experiencing those symptoms is sometimes ignored.

This extends to self-harming and expressing suicidal thoughts, especially in the case of people diagnosed with certain personality disorders such as BPD (borderline personality disorder). They are often negatively and unfairly stereotyped, for example, with symptoms of “manipulative, and attention seeking” behaviour, by the public and by mental health professionals. Therefore, it is perhaps little surprise that hospitals such as Forth Valley Royal over-medicate patients or are unwilling to admit individuals who are genuinely suicidal if they are diagnosed with personality disorders.

‘Self-medicating’ mental illness

Individuals who use drugs are also stigmatised within many Scottish mental health services. The Mental Health Welfare Commission for Scotland reports that 90% of GPs who responded to their study “experienced difficulties in referring patients to both mental health services and addictions services, including when the person presented in crisis.” This is despite many people using drugs to cope with their psychological problems, or ‘self-medicating’. It is often counterproductive to tell a person to deal with their addiction issues first before being considered for hospital admission, as the mental health problem is the reason they use illegal substances in the first place.

If someone has a history of criminal behaviour and their illness has caused them to commit them, then this should not deter them from getting the help they need either, as there should be appropriate treatment available even if not in the local area. The only reason it shouldn’t be offered should be due to a lack of beds, and even this is still a failure of the mental health provision.

The advantages of trauma-informed care

Despite all of this, in 2017 the Scottish Government committed to delivering “trauma informed practice” training to everyone working in the health and social care sector. Trauma informed practice (TIP) acknowledges that our life experiences shape us whether negatively or positively. It recognises the role of ACEs (adverse childhood experiences) in developing mental health problems. For example, people with BPD are 13 times more likely to have reported childhood trauma than someone with no known psychological issues. Similarly, 85 per cent of people with a diagnosis of schizophrenia report ACEs in contrast to 30% in the wider population. TIP has 5 main principles; safety, trust, choice, collaboration and empowerment, which are interconnected and work in tandem with each other.

Safety centres around ensuring the client or service user who has a history of trauma feels physically and psychologically safe in their environment. Many ‘traditional’ medical model practices, such as restraining patients by holding them down and injecting medication – potentially exposing parts of their bodies, all without their consent, can itself be potentially traumatising, especially for victims of sexual abuse. It may cause them to ‘fight back’ and be labelled as violent as a result. Feeling safe could mean setting aside a quiet space, decorating a room in a certain colour and style, and being aware of situations which can make the person feel less at ease.

What language is used is also important. Trust involves creating good relationships with staff through, for example, clients feeling listened to and respected, fostering transparency at all times, and setting realistic and healthy boundaries. Choice relates to the ability for both staff and service users to make their own choices and set their own targets. This is contrary to the medical model which often relies on sectioning patients against their will if they are unwell and forcing certain treatments upon them.

The principles of collaboration and empowerment insist upon service user involvement in treatment plans and goals, as opposed to staff making all the decisions, and they recognise the importance of lived experience in shaping mental health services. Peer support is a good example of this. People with personal experience of mental illness are uniquely placed to understand and empathise with others in a similar situation. While this has become a popular and widespread practice in Scottish mental health services, most of it is unpaid. One would hope that in a truly trauma informed setting, this would not be the case.

Essentially, trauma informed care is based on a ‘what happened to you?’ approach, rather than ‘what is wrong with you?’ as espoused by the medical model of mental illness. It thus encourages empathy and understanding by acknowledging how outside influences affect a person’s wellbeing; it is less judgemental and does not seek to blame and condemn them. This should transform the treatment of patients and service users and lead to a supportive, accommodating and non-discriminatory service.

Potential barriers to trauma-informed practice

There are however barriers to TIP that still remain despite the Scottish government’s commitment to implementing it. The most obvious is underfunding and a lack of provision for people in psychological distress. If people in need are being turned away not because of discrimination but because there are no beds or no appropriate treatment available, TIP is rendered ineffective. Care based on targets potentially takes on clients with less complex needs so as to maximise positive outcomes. Those with a long history of trauma are at risk of being excluded as a result. Building trusting relationships with psychiatrists (and other staff) is difficult when they do not stay in the job longer than 6 months and locums are a staple of mental health services. Repeatedly retelling your experiences to new consultants is often re-traumatising. There is also a dearth of psychologists and talking therapies available under NHS care, and it is not always possible to access the help one needs. People with substance abuse issues are still routinely and widely refused treatment. Staff also need support to cope with the stresses and traumas of working with people on the edge of despair and brokenness. Psychiatric hospitals are places full of hopelessness and it can be difficult – and traumatic – to process what happens in them.

For those who have lost loved ones to the mental health system, and those further traumatised by NHS care, TIP has come too late. There is of course no guarantee that it will be fully implemented in any case. It is often noted that how a society treats its vulnerable is the measure of its humanity. This is the challenge facing the Scottish government today. They need to show how humane and compassionate we truly are, by transforming the face of mental health services for the better.