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Public services that are trauma-informed provide better support for women who have been through traumatic events, but making the transition to this approach can be challenging for many organisations, according to a report published today by Centre for Mental Health and Agenda, the alliance for women and girls at risk.

A sense of safety explores how trauma-informed approaches are being implemented by a range of public services, including mental health services, women’s centres and women’s prisons. It finds that of the services looked at, those taking a holistic approach to supporting women’s needs were best able to make the change to becoming trauma-informed. But, in many organisations it is a long-term process that means changing longstanding ways of working. In others it is made difficult by the environment they are working in or by funding constraints. For many services, short-term and fragile funding, based on targets of volume of service delivery instead of outcomes and quality of the service limited their ability to be innovative and adapt to a truly trauma-informed approach.

A sense of safety calls for all public services to be gender- and trauma-informed. Being trauma-informed means that a service recognises trauma as an important element of a woman’s story and recovery and seeks to empower, build trust and meet her needs respectfully and safely.[1]

While traumatic events can happen to anyone, women experience higher rates of violence and abuse in intimate relationships and are more likely than men to experience poor mental health as a result. Over half of women with a mental health problem have experienced violence and abuse.[2] Despite this, few public services recognise or respond to trauma among women.

The report finds that for services, the transition to being trauma-informed requires ongoing commitment and leadership. It means changing the way staff work with women. It finds that the women’s centres that it looked at were more likely to be trauma-informed than most other services. For services that do adopt a trauma-informed approach there are tangible benefits, not least with increased levels of engagement with women.

One woman when asked about her support from a Women’s Centre that adopted a trauma-informed approached said: “…The staff are amazing; they make you feel safe and as though you can trust them because they actually show an interest…”

A sense of safety calls on the next government to take action to help public services to make the transition to being trauma-informed. This should be included in the next NHS Mandate and future NICE guidelines for health and social care. And bodies like the Care Quality Commission and Ofsted should inspect how well public services are gender- and trauma-informed.

A full list of recommendations is available in the report. They also include:

  • All public service commissioning bodies adopt trauma- and gender-informed commissioning principles for the services.
  • The Department of Health and Social Care and its arm’s length bodies in England, and equivalent bodies in Northern Ireland, should look to developments in Scotland and Wales to support progress towards trauma- and gender-informed public services.
  • The Department of Health and Social Care should lead a research and development programme in England to consolidate the evidence base and produce guidance and resources for a trauma-informed approach.

Centre for Mental Health chief executive Sarah Hughes said: “There is now clear evidence that women who experience trauma in their lives are at a high risk of mental health difficulties that can last a lifetime. Every public service and the people who work in them need to be attuned to this and seek to practise safely. Making this change will not be easy, particularly in services where women’s freedom and choice are restricted. But we cannot ignore the evidence of the benefits of being trauma-informed and the risks of carrying on as we are.”

Jemima Olchawski, chief executive of Agenda, the alliance for women and girls at risk, said: “It’s vital that services take into account women’s specific needs and experiences, especially the impact of trauma and abuse.

“Over a million women in England alone have experienced extensive violence and abuse as both a child and adult. Too often, they struggle to get the help they need from services that fail to understand the impact this can have.  How can we begin to help women recover if we don’t respond to what they’ve been through?

“The Women’s Mental Health Taskforce published by the Government last year encouraged all services to adopt gender and trauma-informed principles. This report shows there is still a long way to go before that becomes a reality.

“That is why the next government must take action and implement trauma-informed care as a priority. Only then will women get the support they need to rebuild their lives.”

About trauma-informed services

Trauma-informed practices move from asking “what is wrong with you?” to “what has happened to you?” They understand and respond to the high prevalence of trauma and its effects, as well as understanding that experiences of trauma can lead women to developing coping strategies and behaviours that may appear to be harmful or dangerous

From Engaging with Complexity (2019)

Key components of trauma-informed services

  • Trauma-informed services put people before protocols
  • The service does not try to make women’s needs fit into pre-specified boxex
  • The service creates a culture of thoughtfulness and communication, and continually learns about and adapts to the individual using their service
  • The service is willing and able to engage with complexity
  • Trauma-informedness is a process and not a set of procedures.

Fundamental processes for a trauma-informed service

  • Listening – Enabling women to tell their stories in their own words
  • Understanding – Receiving women and their stories with insight and empathy
  • Responding – Offering women support that is timely, holistic and tailored to their individual needsChecking – Ensuring that services are listening, understanding and responding in a meaningful way.

About Agenda

Agenda, the alliance for women and girls at risk, works to ensure that women and girls facing abuse, poverty, poor mental health, addiction and homelessness get the support and protection they need. We campaign for systems and services to be transformed; to raise awareness across sectors; and to promote public and political understanding of the lives of women and girls facing multiple disadvantage

[1] Centre for Mental Health and Mental Health Foundation (2019) Engaging with Complexity.

[2] Agenda (2016) Hidden Hurt.

The scale of Traumatic brain injury (TBI) in the general population is only now beginning to be understood.  The T2A programme has published three reports on the TBI and young adult offenders: Repairing Shattered Lives: Brain injury and its implications for criminal justice (October 2012 with University of Exeter), Traumatic brain injury and offending – An economic analysis (July 2016 with Centre for Mental Health) and ‘Young people with TBI in custody’ (July 2016 – with Centre for Mental Health and Disability Trust Foundation) as well as currently supporting screening pilots in prisons.   In December 2016 Andy Bell at the Centre for Mental Health, the writer of this blog, organised a roundtable for experts from the West Midlands at the University of Birmingham to discuss the implications of CMH’s recent research on TBI.  Here he blogs about how early action in addressing TBI could have huge social and economic benefit.

Traumatic brain injury (TBI) is a common and serious health issue. It affects millions of people and carries an economic and social cost of £15 billion a year nationally. People who have sustained a traumatic brain injury have a greater likelihood of mental ill health and of offending, as well as suffering from many other life difficulties.

Barrow Cadbury Trust and Centre for Mental Health recently organised a roundtable for experts from the West Midlands, hosted by the University of Birmingham, to discuss the implications of recent research about TBI and how support might be improved in the West Midlands region.

Addressing TBI in an effective (and efficient) way requires collective action across public services. No agency or sector can deal with it alone. We need a comprehensive approach that includes prevention, early identification and effective support from early childhood and throughout life.

West Midlands Devolution

The West Midlands devolution deal presents a unique opportunity to take a ‘whole place’ approach to TBI. The Combined Authority has already prioritised mental health and youth justice as cross-sector issues it aims to address across the region. Developing an effective response to TBI would contribute to both and to the overall wellbeing of the population.

Preventing head injuries is challenging but action to reduce risk would include measures to tackle domestic violence (the cumulative impact of physical abuse has been noted as a significant problem for women in prison), to promote positive parenting and to tackle bullying in schools. These also have a major impact on emotional wellbeing and future life chances. Improved support for children with ADHD and autism spectrum disorders can also reduce the heightened risk of TBI in these groups of young people. All of these actions should also reduce health inequalities by addressing the greater risks among people in the most deprived and marginalised communities in the West Midlands.

For those who do sustain head injuries, and particularly those who have experienced multiple traumas, identification is vital to ensure that effective support is offered and adjustments are made to reflect their vulnerability. Schools, hospitals, police stations and prisons can all ask simple questions to screen for head injuries. This can help them to ensure they offer support where it is needed, for example to manage a child’s behaviour in school and avoid excluding a young person whose behaviour results from a head injury where some additional support might be of benefit.

TBI and the Criminal Justice System

It is estimated that up to 60% of prisoners have sustained head injuries. It is therefore vital that the whole of the criminal justice system works with an awareness of TBI and an ability to respond effectively. Liaison and diversion teams, for example, can screen for TBI alongside other vulnerabilities. Prisons can offer all of their staff (including not just prison officers but education and other workers) training about TBI as part of becoming an enabling environment. Specialist linkworkers in prisons have also been found to provide effective support to individuals with TBI. And for people leaving prison, robust support is essential to help them to adjust to life outside and cope with the demands and difficulties they will face.

There are a number of initiatives already in place to build upon: HMP Drake Hall provides all staff with training in working with trauma and supports women prisoners who have experienced abuse and violence. The Geese Theatre Company provides ‘safe spaces’ for prisoners to explore their emotional wellbeing and what would help them to get back in control of their lives. And there are specialist services for offenders in the community, including for women, that offer peer support and help with health issues,  that could provide more bespoke support for those with head injuries.

The significance of TBI is only beginning to be understood. But it is now clear that joint action that brings together local authorities, NHS organisations, schools, the criminal justice system and voluntary and community bodies (among others) will be essential to develop an effective response. From public health teams including TBI in local needs assessments and Health and Wellbeing Strategies to schools providing extra support to children who have sustained head injuries, we can bring about a bigger focus on prevention and early help. And by working across the justice system, we can enable some of the most vulnerable and prolific offenders to get their lives back on track.