How do mental health services respond when child abuse or neglect become known? A literature review

Routine Sensitive Enquiry of Adult Interpersonal Trauma in Community Mental Health Teams: An Audit of the Initial Assessment Tool

This audit aimed to evaluate the utility of the Initial Assessment Tool (IAT) in documenting routine sensitive enquiry of adult interpersonal trauma within three Community Mental Health Teams (CMHTs) in North-East Glasgow. In addition, it sought to evaluate if disclosures informed patient risk assessments and if patients were signposted to additional support services. 57% of 90 IATs had evidence of routine sensitive enquiry. Of 51 casefiles with evidence of routine sensitive enquiry, 61% had evidence of the information informing their risk assessments and 14% had documented recommendations of support organisations. The IAT appeared able to assist clinicians with routine sensitive enquiry in adulthood. However, there may be advantage in supporting staff understanding of how to ask questions to specific populations and to use this information to inform treatment planning. Given the prevalence of adult interpersonal trauma experienced by patients presenting to CMHTs, trauma-informed approaches to care should be implemented.

The ongoing importance of the routine enquiry into trauma and abuse and trauma-informed care within mental health trusts in England

WHAT IS KNOWN ON THE SUBJECT?: A significant number of people with mental health diagnoses have also experienced some form of trauma. In 2008, it was recommended that MHTs in England provide training to MHPs to support them in how to ask their service users about trauma and abuse. It has been identified that staff are not consistently enquiring about trauma and abuse in mental health services. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: A description of how many MHTs in England are providing training for staff to ensure that they enquire about trauma and abuse. The current gaps in the resources available for mental health practitioners and staff. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Much more work and development of trauma-informed care and accessibility of training is needed for MHPs working in MHTs. Most MHTs still need to take the first step of implementing training in trauma-informed care. This should involve ways to ask about trauma and abuse and advice on how to respond to any disclosures made.

ABSTRACT

INTRODUCTION: Trauma, abuse and adversities are extremely prevalent for those who access secondary mental health services. Health policy guidance recommends that mental health professionals (MHPs) should routinely enquire about trauma and abuse. Staff training is required to adopt trauma-informed approaches, as research has identified a clear gap in practice. This study provides a baseline measure of the current provision of trauma-informed training in English mental health trusts (MHTs).

QUESTION

What trauma-informed training is currently available for MHPs in England?

METHOD

A freedom of information request was submitted to 52 MHTs in England to explore the current training available for MHPs in trauma-informed care, routine enquiry into abuse and responding to disclosures.

RESULTS

The results showed 70% of respondents reported no available training in trauma-informed care.

DISCUSSION

Many MHTs in England do not provide any trauma-informed training (despite existing recommendations from 2008). Does this contribute to the re-traumatisation of patients?

IMPLICATIONS FOR PRACTICE

MHTs in England require a responsible and active approach to training MHPs in sensitive routine enquiry into trauma and abuse as a first step to becoming trauma responsive.

Examining the Relationship Between Trauma, Post‐Traumatic Stress Disorder and Psychosis in Patients in a UK Secondary Care Service

Objective

Traumatic experiences and post-traumatic stress disorder (PTSD) are common in schizophrenia. However, few studies screening for PTSD have established the temporality of PTSD-related traumatic events to psychosis onset. Furthermore, it is unclear how many patients attribute a trauma-based contribution to their psychosis or would find trauma-focused therapy acceptable. We examine the prevalence and timing of trauma in psychosis, as well as patient views on the relationship between their trauma experiences and mental health difficulties, and on receiving trauma-focused therapy.

Methods

Sixty-eight patients with an at-risk mental state (ARMS) or psychotic disorder in a UK secondary-care setting completed self-report measures of trauma and PTSD, and undertook research interviews. Proportions and odds ratios were derived with 95% confidence intervals.

Results

We recruited 68 participants (estimated response rate 62%; psychotic disorder n = 61, ARMS n = 7). Sixty three (95%) reported traumatic events and 32 (47%) reported childhood abuse. Twenty-six individuals (38%) met criteria for PTSD, though for >95% this was not recorded in their notes, and 25 (37%) had sub-threshold PTSD. For 69% of participants, their worst trauma occurred before the onset of their psychosis symptoms. Most (65%) believed their psychosis symptoms were related to past traumas and 82% of these were interested in receiving trauma-focused therapy.

Conclusions

PTSD is common in and often pre-dates onset of psychosis. Most patients believe their symptoms and traumas are related and would be interested in trauma-focused therapy if available. Studies evaluating the effectiveness of trauma-focused therapies for those with or at high-risk of psychosis are required.

Disentangling the impact of childhood abuse and neglect on depressive affect in adulthood: A machine learning approach in a general population sample

BACKGROUND

Different types of childhood maltreatment (CM) are key risk factors for psychopathology. Specifically, there is evidence for a unique role of emotional abuse in affective psychopathology in children and youth; however, its predictive power for depressive symptomatology in adulthood is still unknown. Additionally, emotional abuse encompasses several facets, but the strength of their individual contribution to depressive affect has not been examined.

METHOD

Here, we used a machine learning (ML) approach based on Random Forests to assess the performance of domain scores and individual items from the Childhood Trauma Questionnaire (CTQ) in predicting self-reported levels of depressive affect in an adult general population sample. Models were generated in a training sample (N = 769) and validated in an independent test sample (N = 466). Using state-of-the-art methods from interpretable ML, we identified the most predictive domains and facets of CM for adult depressive affect.

RESULTS

Models based on individual CM items explained more variance in the independent test sample than models based on CM domain scores (R² = 7.6 % vs. 6.4 %). Emotional abuse, particularly its more subjective components such as reactions to and appraisal of the abuse, emerged as the strongest predictors of adult depressive affect.

LIMITATIONS

Assessment of CM was retrospective and lacked information on timing and duration. Moreover, reported rates of CM and depressive affect were comparatively low.

CONCLUSIONS

Our findings corroborate the strong role of subjective experience in CM-related psychopathology across the lifespan that necessitates greater attention in research, policy, and clinical practice.

Adequacy of Inquiry About, Documentation of, and Treatment of Trauma and Adversities: A Study of Mental Health Professionals in England

This study aimed to ascertain how often staff in community mental health services (CMHSs) in England ask about adverse experiences in childhood and adulthood, including abuse and neglect, how often those experiences are known about and documented by staff, and how staff respond when such experiences are known about and documented. The files of 400 people using four CMHSs in England were reviewed. Only 13% of clinical records contained documentation of any adverse experiences. One percent showed clear evidence that clients had been asked about adversities. People with psychosis diagnoses were less likely to have adverse experiences documented in their file. Rates of responses to adversities of which staff were aware were high, with 90% of records indicating some appropriate support following disclosure. Future research endeavours are recommended, including on reasons for not routinely asking and on type of training needed. Recommendations are made in relation to policy change, staff training and guidelines to improve routine enquiry about adversities. Ultimately, a move to 'trauma-informed' services, already underway in some areas, is required for all mental health services.

The impact of adverse childhood experiences and recent life events on anxiety and quality of life in university students

Adverse childhood experiences (ACEs) have been repeatedly associated with a wide range of physical and mental health issues. Research has indicated high levels of anxiety and depression among university students, and a few studies have documented the relationship between ACEs and anxiety in the university student population. This study surveyed first year students at a university located in the most ethnically diverse district in England, with the second highest poverty rate. Eight hundred and fifty-eight responded; a response rate of 12%. The survey included questions about adverse childhood events, recent life stressors, current deprivation, quality of life, positive physical health and positive mental health, and used the Generalized Anxiety Disorder Scale, a standardised measure. Thirty-seven percent of the responding students met the diagnosis for generalised anxiety disorder. In a multivariate multiple regression model, life stressors and childhood adversities were significantly associated with higher levels of anxiety and lower levels of physical and mental health. Only childhood adversities significantly predicted lower levels of quality of life. The findings highlight the importance of considering adverse childhood experiences in enhancing the wellbeing of the student population. Given the demographics of the student population at the University of East London, the high rates of ACEs and anxiety are likely to partially reflect poverty and racism. The implications of the findings for trauma-informed policies and practices in universities are discussed.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s10734-021-00774-9.

A retrospective study examining the adverse effect of childhood abuse among adult psychiatric service users in Britain

The long-term effects of childhood abuse have been well studied though the effects of abuse of specific types in adult psychiatric service users are less known. This study aimed to assess the association between childhood abuse and the development of harmful social and behavioural outcomes among adult psychiatric service users. Adult psychiatric service users were accessed from secondary mental health services in South London. A retrospective analysis was conducted of a randomly selected sample of 342 mental health records. Chi-square tests and logistic regression models were used to examine associations between childhood abuse - sexual abuse, physical abuse and psychological/emotional abuse - and health and behavioural outcomes. This study identified that 109 (31.8%) psychiatric service users had some history of childhood abuse and more often presented with high-risk or severe behaviours. Sexual abuse in childhood was linked with social isolation related to loss of friends (odds ratio (OR) = 2.68, P < 0.01), risky behaviours such as binge drinking (OR = 2.15, P < 0.05) and self-harming (OR = 2.86, P < 0.01), while childhood physical abuse was associated with drug abuse in adulthood (OR = 1.88, P < 0.05). Revictimization (adult domestic violence) also impacted on service users' quality of life in terms of loss of housing (OR = 2.21, P < 0.05) and loss of friends/family contact (OR = 2.73, P < 0.01). These findings suggest childhood abuse may play an important role in shaping risk and vulnerability for mental health problems across a lifespan. In acute mental health services, the incorporation of a trauma-informed nursing care model is necessary to generate a shift in culture in the delivery of care.

Prevalence and associated mental health outcomes of child sexual abuse in youth in France: Observations from a convenience sample

CONTEXT

Child sexual abuse (CSA) is an important public health problem associated with an array of negative consequences. Although prevalence rates are well established from North America, few studies have focused on the extent of CSA and associated outcomes in youth from France.

OBJECTIVES

This study aimed to: 1) estimate the prevalence of CSA, 2) assess the associations between CSA and health outcomes while exploring possible gender specificities and 3) document the contribution of revictimization on symptom complexity.

METHOD

The sample involved 2309 participants aged between 14 and 23 years old (M = 19.55). Measures assessing CSA, other forms of child maltreatment and mental health problems were administered. Sexual revictimization and a host of protective factors (resilience, coping strategies, parental support) were also assessed.

RESULTS

CSA was reported by 13.1% of girls and 4.2% of boys. Regression analyses revealed that CSA was associated with all mental health outcomes except alcohol and drug use (other than cannabis) after controlling for sociodemographics and other forms of child maltreatment. Sexual revictimization was associated with symptom complexity. Emotion-centered and avoidance coping predicted symptom complexity while resilience and paternal support acted as protective factors.

LIMITATIONS

The study relied on a cross-sectional design with a convenience sample, which limits the generalizability of results. The small number of boys reporting CSA precludes drawing firm conclusions as to the gender specificities in the outcomes associated with CSA.

CONCLUSIONS

Findings underscore the relevance of developing efficient prevention programs as CSA is linked to a host of negative outcomes.

Psychological processes mediating the association between developmental trauma and specific psychotic symptoms in adults: a systematic review and meta-analysis

Experiencing psychological trauma during childhood and/or adolescence is associated with an increased risk of psychosis in adulthood. However, we lack a clear knowledge of how developmental trauma induces vulnerability to psychotic symptoms. Understanding the psychological processes involved in this association is crucial to the development of preventive interventions and improved treatments. We sought to systematically review the literature and combine findings using meta-analytic techniques to establish the potential roles of psychological processes in the associations between developmental trauma and specific psychotic experiences (i.e., hallucinations, delusions and paranoia). Twenty-two studies met our inclusion criteria. We found mediating roles of dissociation, emotional dysregulation and post-traumatic stress disorder (PTSD) symptoms (avoidance, numbing and hyperarousal) between developmental trauma and hallucinations. There was also evidence of a mediating role of negative schemata, i.e. mental constructs of meanings, between developmental trauma and delusions as well as paranoia. Many studies to date have been of poor quality, and the field is limited by mostly cross-sectional research. Our findings suggest that there may be distinct psy-chological pathways from developmental trauma to psychotic phenomena in adulthood. Clinicians should carefully ask people with psychosis about their history of developmental trauma, and screen patients with such a history for dissociation, emotional dysregulation and PTSD symptoms. Well conducted research with prospective designs, including neurocognitive assessment, is required in order to fully understand the biopsychosocial mechanisms underlying the association between developmental trauma and psychosis.

Testing the neurodevelopmental, trauma and developmental risk factor models of psychosis using a naturalistic experiment

BACKGROUND

The neurodevelopmental and trauma theories are two widely cited models of psychosis. A third - the developmental risk factor model (DRFM) - recognises the combined role of neurodevelopmental risks and trauma. Our objective was to test these theories using preterm populations as a natural experiment, given the high prevalence of neurodevelopmental deficits and exposure to trauma.

METHODS

Two population-based preterm birth cohorts, the Bavarian Longitudinal Study (BLS; N = 399) and EPICure Study (N = 184), were included with term-born controls. Peer victimisation in childhood was assessed by parent and child report and psychotic experiences (PE) were assessed in early adulthood. Different models of psychosis were tested using regression and mediation analyses.

RESULTS

There was support for the trauma and DRFM in the BLS. Peer victimisation increased the risk of PE for preterm and term-born participants equally [odds ratio = 4.87, 95% confidence interval (CI) 1.96-12.08]. There was an indirect effect where preterm children were more likely to be victimised, which subsequently increased risk of PE [β = 1.12 (s.e. = 0.61), 95% CI 0.11-2.48]. The results were replicated in EPICure.

CONCLUSIONS

Exposure to trauma which is experienced more often by neurodevelopmental risk children rather than neurodevelopmental risk per se increases the risk of PE. The findings are consistent with the trauma model and DRFM. Interventions focused on reducing trauma may reduce the development of PE.

A “trigger”, a cause or obscured? How trauma and adversity are constructed in psychiatric stress-vulnerability accounts of “psychosis”

How do mental health professionals link adverse life experiences with the kinds of beliefs and experiences which attract a diagnosis of psychosis and what implications does this have for women with these diagnoses? Drawing on a broadly critical realist framework, we present data from two studies relevant to these questions. First, we analyse the discursive practices engaged in during a staff-only discussion of a female in-patient with a psychosis diagnosis who had been raped some years previously. Staff oriented to the irrationality and factuality of her ostensibly delusional statements about rape and pregnancy in the present and formulated adverse experience as a “stress factor” triggering a manic episode, thereby precluding alternative contextualising interpretations. In a second, interview-based, study, psychiatrists drew on a range of discursive resources which differentiated “psychosis” from other forms of distress, constructed trauma as a stressor which could trigger psychosis because of a genetic predisposition, and constructed medication as the primary intervention whilst trauma was de-emphasised. We discuss the implications of these findings for the kinds of explanations and forms of help offered and suggest ways in which distress might be contextualised as well as possible future directions for feminist research and practice.

Peer-led groups for survivors of sexual abuse and assault: a systematic review

Background: There are current concerns about whether appropriate support is provided for sexual abuse and assault survivors. We reviewed the published evidence for peer-led groups in the care of survivors.Aims: To determine the health and wellbeing outcomes of peer-led, group-based interventions for adult survivors who have experienced sexual abuse and assault and describe the experiences of participants attending these groups.Method: Systematic review. The following databases were searched: Medline, PsycINFO, Embase, Cochrane Library, Web of Science, Sociological Abstracts, IBSS. Papers focusing on adults using any research methodology were included. Quality appraisal was completed using the Mixed Methods Appraisal Tool (MMAT). Thematic analysis was undertaken using methods of constant comparison.Results: Initial, and updated searches identified 16,724 potentially eligible articles. Of these, eight were included. Thematic analysis revealed that peer-led group-based interventions have positive impact on participants' psychological, physical and interpersonal well-being. Participation also presents challenges for survivors. However, there is a mutuality and interconnected benefit between the triggering of difficult emotions due to participation and the healing experiences gained.Conclusions: Scientific evidence of peer-led, group-based, approaches for adult survivors of sexual abuse and assault is limited, although generally suggestive of benefits to such individuals.

Trauma-informed care for adult survivors of developmental trauma with psychotic and dissociative symptoms: a systematic review of intervention studies

Developmental trauma is associated with an increased risk of psychosis and predicts poor prognosis. Despite this association, little is known about which treatments work best for survivors of developmental trauma with psychosis. We sought to do the first review, to our knowledge, to investigate treatments for people with psychotic and dissociative symptoms who have a history of developmental trauma. We searched MEDLINE, PsychINFO, and Google Scholar for studies reporting psychological and pharmacological treatments of psychotic or dissociative symptoms in adult survivors of developmental trauma. We identified 24 studies, most of which investigated various modalities of psychotherapy with two case reports of pharmacological treatments. There is preliminary evidence in favour of third wave cognitive therapies. However, because of low methodological quality and reporting in most of the studies found, it remains unknown which treatments are most effective in this clinical group. Nonetheless, our findings of potential treatment targets, including emotion regulation, acceptance, interpersonal skills, trauma re-processing, and the integration of dissociated ego states, could guide future work in this area. Methodologically rigorous studies are needed to enable clinicians and patients to collaboratively form evidence-based treatment plans. Our Review is registered with PROSPERO, number CRD42018104533.

Bad things happen and can drive you crazy: The causal beliefs of 701 people taking antipsychotics

In almost all countries the public prefers psycho-social explanations of 'schizophrenia' to bio-genetic ones. The causal explanations of people who experience psychosis have been under-researched, and, if they diverge from the dominant bio-genetic paradigm, can be dismissed as 'lack of insight'. 701 people, from 30 countries, who completed an online survey about their experiences on antipsychotics, answered an open question about what had caused the problems for which they had been prescribed the drugs. On a 'Bio-Social' likert scale, from 1 = 'Purely Biological' to 5 = 'Purely Social', the mean score was 4.24. Thematic analysis of 1,063 causal statements produced seven themes: Social (49.9%), Psychological (12.1%), Bio-genetic (11.6%), Iatrogenic (11.3%), Drug and Alcohol (6.7%), Medical Condition (4.5%) and Insomnia (4.0%). Respondents were 13 times more likely to report predominantly or exclusively Social causes as to report predominantly or exclusively Bio-genetic causes. Those with a psychosis diagnosis were even more likely than others to report a Social cause. The causal beliefs of this sample are consistent with previous studies of people diagnosed with 'schizophrenia' and the beliefs of the public. They are also aligned with recent research into the social causes of psychosis. It is argued that rather than dismiss the beliefs as 'lack of insight' it is more respectful and productive to listen carefully and adjust our understandings and services accordingly.

Reducing barriers to trauma inquiry in substance use disorder treatment - a cluster-randomized controlled trial

BACKGROUND

Despite the high rate of traumatic events in clients with substance use disorders, trauma exposure often remains undetected in a majority of treatment-seeking clients. Improving health professionals' knowledge and skills in the inquiry of traumatic events is therefore of utmost importance for appropriately addressing trauma-related treatment needs. However, professionals in substance use disorder treatment settings frequently report barriers to the inquiry about traumatic events, e.g., the fear of offending or harming the client. Such barriers should be addressed by trainings that aim to improve the systematic inquiry of traumatic events.

METHODS

Using a cluster-randomized trial, we examined whether a one-day training in trauma inquiry ('Learning How to Ask') would reduce professionals' perceived barriers to trauma inquiry. One hundred forty-eight professionals working in outpatient substance use disorder treatment centers were randomized to an intervention (n = 72) or a control group (n = 76). The professionals in the intervention group received a one-day training plus a refresher session 3 months later, the professionals in the control group received no training. At baseline, and at 3-month and 6-month follow-up, professionals rated on a four-point Likert scale regarding how strongly they agreed with statements about six common barriers to trauma inquiry, namely 'Feeling uncomfortable when asking about traumatic events', 'Fear of offending the client', 'Fear of retraumatizing the client', 'Fear that client may terminate treatment', 'Unsure whether authorities have to be informed when perpetrator is known', and 'No trauma-specific treatment available in my local area'.

RESULTS

The trained group experienced significant greater decreases in five of the six perceived barriers to the inquiry of traumatic events from baseline to 6-month follow-up than the control group ('Feeling uncomfortable when asking about traumatic events': b = - 0.32, 95% CI [- 0.52, - 0.12]; 'Fear of offending the client': b = - 0.33, 95% CI [- 0.56, - 0.09]); 'Fear of retraumatizing the client': b = - 0.45, 95% CI [- 0.69, - 0.22]; 'Fear that client may terminate treatment': b = - 0.28, 95% CI [- 0.49, 0.07]; 'No trauma-specific treatment available in my local area': b = - 0.25, 95% CI [- 0.51, - 0.01]).

CONCLUSIONS

Our findings provide first evidence that a one-day training in trauma inquiry is effective in reducing common barriers to trauma inquiry, which may in turn improve detection of traumatic events.