Enablers and barriers to trauma-informed systems, organisations and workforces: evidence review

Section 1: Introduction

1.1 Key terms and definitions

What is trauma?

Individual trauma results from an event, series of events, or set or circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional or spiritual wellbeing. The term 'trauma' or 'psychological trauma' refers to how a person experiences the event(s), recognising that individuals can experience the same event(s) differently. The experiences can be a single or repeated occurrence and the effects may occur immediately or be delayed (or both), may be long- or short-term, and may not be recognised as connected to the original trauma. Essentially, trauma is understood in terms of the "3 E's": the event, how it is experienced, and its effects. (Transforming Psychological Trauma Knowledge and Skills Framework, NHS Education for Scotland, 2017)

Individuals may experience and be impacted by trauma at any point(s) across the life-course and trauma typically occurs in the context of relationships. Trauma is often subdivided into Type 1 and Type 2 trauma, but it is not uncommon for people to experience both types during their lives:

Type 1 trauma – These are usually single incident events that are sudden and unexpected, such as rapes, assaults, or serious accidents, such as road traffic accidents. Type 1 trauma can also include terrorist attacks or other types of major emergencies. These can happen in childhood or adulthood and can involve life changing injuries or the loss of loved ones.

Type 2 or "complex trauma" – This term refers to repeated trauma, which is usually experienced in the context of relationships, persists over time and is difficult to escape from. These traumatic events often (although not always) occur in childhood, with significant potential risk of developmental impact. The most commonly studied example of complex trauma is child sexual abuse. However, it can also be experienced in adulthood, in particular with experiences of domestic abuse, and also in the context of war, torture or human trafficking.

The Impacts of Trauma

The Transforming Psychological Trauma Knowledge and Skills Framework, (NHS Education for Scotland, 2017) outlines a number of different and overlapping impacts of trauma. Their definitions are as follows:

Direct psychological and physiological impacts: As a result of exposure to threatening or unsafe situations, in particular for children (but also for adults), neurological and cognitive processes adapt to detect, avoid and manage the impact of (often extreme) threat. The development of a highly sensitive threat system is potentially life saving during times of trauma. However, maintaining 'high alert' over time can have longer-term, negative physiological and psychological impacts. Prolonged trauma, particularly in childhood, can also cause longer-term difficulties by limiting cognitive, social and emotional development and opportunities for learning and for developing skills in managing relationships with peers

Coping responses: A person's adaptive responses, for example "tuning out", dissociation or avoidance, can be helpful in the short-term, but can become problematic longer-term, as they can compromise active coping and restrict life choices. The use of substances and self-harm can also be understood as attempts to manage distress linked to past trauma which carry additional risks and compound difficulties.

Relationships with others: As noted earlier, trauma typically occurs in the context of relationships. Such experiences of interpersonal trauma, particularly in childhood, can disrupt the ability to form and maintain healthy and supportive relationships with others. Forming unhealthy and unsafe relationships also has the potential to compound previous trauma through an increased risk of re-victimisation. This is important as safe and supportive relationships are the best predictors of recovery following trauma.

Help seeking and engagement with services: People affected by trauma can become highly sensitive to subtle (as well as obvious) reminders of their previous traumatic experiences and relationships. Such reminders, and the distress that they cause, and the impacts of trauma on relationships, can mean that people who are affected by trauma do not seek or receive the help, care and support that they need. This compounds the risks of poorer outcomes following trauma. Hence, the importance of developing trauma-informed workforces and services.

Wide-ranging studies have added to the growing evidence that large numbers of people in contact with public services have experienced traumatic events. The 'Hard Edges Scotland' study (Bramley, Fitzpatrick and Sosenko, 2019) found that growing-up with experiences of trauma, combined with poverty, underpins severe and multiple disadvantage experienced by adults in Scotland. Their needs have often not been met by services and they can experience a range of challenges including addiction, mental health problems, and homelessness.

What does it mean to be 'trauma-informed'?

Being 'trauma-informed and responsive' means being able to recognise when someone may be affected by trauma, collaboratively adjusting how we work to take this into account and responding in a way that supports recovery, does no harm, and recognises and supports people's resilience. (NHS Education for Scotland, 2017)

1.2 Research aims

The main aim of this report is to determine the strength of the evidence base underpinning trauma-informed systems, organisations and workforces. More specifically, this review looks at the key elements that are the biggest predictors of:

• improving people's experiences of those systems, organisations and workforces, and
• improving outcomes for people with lived experience of trauma.

These two areas represent the intended outcomes that trauma-informed systems, organisations and workforces are aiming to bring both to staff and people with experience of trauma .

1.3 Methodology

This report is based on a rapid evidence review of the literature exploring the implementation of trauma-informed approaches in systems, organisations and workforces, and the predictors that could bring the biggest improvements (in the short, medium, and long term) for those involved with them. As this is a rapid evidence review, it should not be considered comprehensive in its coverage. The evidence identified was analysed using a decision-making tool which helped to classify predictors according to their effectiveness in bringing positive changes to people (staff and those with lived experience of trauma) involved with those systems, organisations and workforces.

Search strategy and screening

A literature search and evidence summary on the outcomes of trauma-informed care or trauma-informed practice was carried out. It focused on:

• the empirical evidence (peer reviewed literature) available for the outcomes of trauma informed approaches to systems change, and
• examples of trauma-informed approaches being applied at the whole-system level (e.g. state, city, region, professional group) and the quality indicators / systems have been used to monitor them.

The key terms "trauma informed" OR "trauma responsive" AND outcomes OR effectiveness OR study (etc.) were used to search three databases: Medline, Embase, and PsycInfo. Inclusion criteria included literature written in English and published from 2017 onwards. A first search was conducted in January 2020 and then repeated in January 2022. A total of 2420 studies were identified once duplicates were removed.

2022 search

Total: 4109 references

1682 ('trauma-informed' in the title/subject field)

2427 ('trauma-informed' in other field)

After de-duplication: 2421

997 (title/subject field)

1424 (other field)

After initial screening: 77 references

2020 search

Total: 84 references, comprising:

60 references selected in 2020

24 additional references selected after rescreening the remaining 2020 results

After initial rescreening of 2020 results: 38 references

Combined results of 2022 and 2020 searches after initial screening: 115 references

After final screening: 60 references

19 papers provided data on outcomes from system-level trauma informed approaches

4 additional papers provided data on outcomes from interventions that involved staff education

10 references had possible assessment tools

27 references gave examples of system- or organisation-wide trauma-informed approaches

A summary of the most substantial papers (N = 24) that were used to develop this analysis can be found in Appendix B. The studies and literature reviews included in the analysis are those that clearly evaluated or discussed the impact of trauma-informed interventions on individual or organisational outcomes. When using the evidence of effectiveness decision tree, the following aspects were considered when classifying the available evidence:

• the relevance of the evidence: must include outcomes related to the impact of trauma-informed approaches on staff and people with lived experiences of trauma
• what the evidence says about the effectiveness of the different components, or of the whole intervention
• the strength of the available evidence (for example, was a control group included in the study design or is there a clear link between intervention components and outcomes?)

When considering the strength of the available evidence the following limitations were identified across the research literature:

• Heterogeneity of interventions
• Heterogeneity of measures and outcomes assessed
• Lack of control / comparison groups
• Lack of empirical evidence
• Small sample sizes

Data analysis

A decision-making tool and an evidence of effectiveness decision tree were used to classify the different strategies (enablers) within trauma-informed programmes identified in the evidence review according to their effectiveness in improving the experiences of people involved with different services (education, child welfare, etc.). Although the intention was to assess the effectiveness of these strategies in bringing positive changes in the short, medium and long term, the evaluation is limited to short and medium term outcomes due to the lack of research exploring longer term effectiveness.

The decision-making tool and evidence of effectiveness decision tree have been previously utilised in preceding Scottish Government reports (see Scottish Government, 2020). The approach taken here differs from how the decision-making tool has been used in other evidence reviews. In this study individual elements of interventions and programmes were analysed, as opposed to whole programmes or initiatives (e.g. Scottish Government, 2020). This decision was made to meet the goals set for this evidence review which aimed at identifying predictors or enablers that might bring the most significant improvements for individuals and organisations.

As not all the categories in that decision tree were present in the evidence from the literature review, the effectiveness ratings were reduced from six categories to three. An effectiveness rating was assigned to the different predictors identified. The effectiveness categories used to classify these predictors or enablers were as follows:

• Effective – Evidence that the intervention is associated with a positive impact on the outcomes of staff working within different services, systems, and organizations, and people with lived experience of trauma involved in those systems, based on a moderate or strong evidence base.
• Promising – Findings were positive but not to the extent that they constituted evidence that an intervention was 'effective'. Similarly, a body of evidence that is mostly comprised of individual articles (or an article with mixed evidence of effectiveness) finding a 'mixed' impact of interventions would be considered 'promising" overall.
• Inconclusive – Insufficient evidence to make a judgement on impact

Further details about the the decision-making tool are provided in Appendix A.