By Jennie Chapman
Anthony, 31, has just been to A+E with severe gastro-intestinal pain. This is his sixth visit in four months with the same symptoms. He is visibly in discomfort, and tells you he has been taking opioids for years, in escalating doses, to address a chronic gastrointestinal condition. He also discloses that he has increasingly used alcohol alongside the painkillers, stating that he struggles to sleep otherwise.
Anthony has a history of becoming angry and confrontational when healthcare professionals have suggested he may have developed an addiction to opioids. He contends that he wouldn’t be on the painkillers if the doctors diagnosed him properly. While discussing this, his demeanour becomes increasingly defensive and belligerent.
When he calms down, you are able to learn a little more about his past: he tells you he has battled anxiety and panic attacks since he was a child. He discloses a number of adverse childhood experiences: a violent father; a mother who battled a benzodiazepine dependency which was barely recognised, let alone treated; a backdrop of deprivation and poverty.
Currently, Anthony believes opioids and alcohol are the only relief for his emotional, psychological and physical pain.
Anthony is fictional, a composite of so-called ‘difficult-to-engage’ individuals caught in the crosshairs of trauma, substance use disorder, physical illness and mental distress – but his circumstances and presentation are probably familiar to many working in and around services such as ours.
Anthony may at one time have been labelled as ‘difficult-to-engage,’ his erratic behaviour generating wariness and distrust among hard-pressed professionals already burdened with a multitude of complex cases who are in just as much need as he is, perhaps more. His angry outbursts may have alarmed key workers sufficiently for him to be noted as a ‘non-compliant’ or ‘challenging’ patient, affecting the care he receives. Some teams or agencies may be reluctant to work with him at all. The more Anthony feels dismissed and unheard, the more reactive he becomes. A negative feedback loop sets in. After many months and multiple, ultimately unsuccessful, interventions, Anthony is increasingly perceived as ‘beyond help’, a view that Anthony himself internalises to the further detriment of his wellbeing. Perhaps at this point Anthony disengages from services and support entirely. His physical and mental health worsen and his substance dependency deepens: in his view, the betrayals and neglect that marred his childhood are being played out all over again.
How might a trauma-informed approach have changed the care Anthony received, and the outcomes he experienced?
Trauma-informed practice, or trauma-informed care, provides us with a different lens through which to view Anthony and others in his position. Instead of asking, ‘what’s wrong with him’, it asks ‘what happened to him?’ According to trauma expert Susan Salasin, it starts with the “assumption that every person seeking services is a trauma survivor” deserving of “humane, dignified, cost-effective, genuinely person-centred support.” It understands challenging behaviours not as evidence that an individual is in some way defective or dysfunctional, but as symptoms of past traumas, in which the individual was harmed, deceived, abandoned or betrayed by someone they trusted or depended upon.
Using trauma-informed principles allows us to recognise that behaviours such as Anthony’s are underpinned by multiple adversities. His profound and chronic physical pain makes him edgy and quick to anger – tendencies which are further compounded by the hypervigilance and heightened alertness to perceived threats that arise from his history of trauma. His anxiety and depression mean he struggles to regulate his emotions, while his ACEs (adverse childhood experiences) have resulted in trust issues, especially around figures of authority.
By adopting the core principles of trauma-informed care, including safety, transparency, accountability, choice and empowerment, a trauma-informed practitioner would seek to develop a bond of trust with Anthony, which would in turn create a safe space in which they could work together to build up a picture of his past in order to make sense of his present. They might explore the triggers that ignite his trauma responses, which up till now had been labelled as ‘challenging’ or ‘difficult’, and look at strategies and techniques for managing them. They may also explore harm reduction methods to address his poly-substance use and mitigate the associated risks, while working in a non-judgmental manner to help Anthony recognise why he uses painkillers and alcohol, and explore alternative means of coping that might open up a pathway to recovery.
Rather than being framed as a passive individual to be ‘managed’ – a person who has decisions made about them and things done to them – Anthony’s autonomy is restored in this scenario, as he takes ownership of his recovery with the support of professionals and, importantly, peers. As he learns to trust others – and himself – and grows in confidence, Anthony perhaps decides he could use his experiences positively, to support and empower others. It is a model that we see in action every day at Red Rose Recovery, through the work of our lived experience staff, volunteers, and community of peers.
Last year Red Rose Recovery was among the first organisations to sign up to the Trauma-Informed Lancashire initiative, a multi-agency strategy led by the Lancashire Violence Reduction Network. The movement encompasses a range of services and organisations in multiple sectors, including health and social care, education, criminal justice, and the third sector. These organisations have collectively pledged to engage in a wholesale transformation of our working practices and cultures – one which recognises, responds to and resists the damaging impacts that trauma has on individuals, families, communities and society as a whole.
The journey to becoming trauma-informed is long and demanding – it cannot be undertaken via a few policy amendments and awareness-raising events, but requires comprehensive culture change, extensive and ongoing training and support for staff and volunteers, and a commitment to approaching every interaction – not only with service users, but between colleagues, many of whom have their own lived experiences of trauma – with trauma-informed intent. The efforts are considerable, but so are the rewards.
For more information on Trauma-Informed Lancashire, see https://www.traumainformedlancashire.co.uk