National Trauma Transformation Programme: Trauma-Informed Substance Use Pathfinders – Learning Report

Service Design and Delivery

The way a service is designed and delivered, its processes and pathways and how these interact with other services can all impact on whether a service is trauma-informed and whether it minimises distress, avoids re-traumatisation and supports recovery.

The journey of a person who uses a service or organisation can often highlight where they have positive experiences or face barriers or discomfort. These journeys may involve interactions with many staff and systems. Viewing service pathways and journeys in a holistic fashion can highlight experiences with individuals, processes and environments that can be reinforced or improved to address TI Practice.

Challenges in the Pathfinder areas

Physical environment is important in ensuring physical and emotional safety for all people who have experienced trauma (staff and people using the service). In one area, a lack of suitable facilities made it difficult to implement TI Practice. For example the size of available meeting rooms did not allow for enough people to join meetings; staff were located in a small office and there was stigma evidenced in the treatment of people using services. This latter issue highlights the importance of training reception staff and all people coming into contact with people using the services.

In another area where facilities were more appropriate, emotion regulation boxes^[15] were made available to support staff and service user wellbeing by giving them space and materials to help keep them in their Window of Tolerance.

In both pathfinder areas, it was apparent there were challenges in accessing Psychological Services for people using the service. This was primarily due to lack of inbuilt psychological input into the drug and alcohol teams, as well as abstinence criteria in place stating people needed to be abstinent from drugs and alcohol for 3 months prior to starting psychological therapy. Services have started to review these abstinence criteria and develop improved pathways to psychology. Over the course of the pathfinder, services had also recognised and had started to embed Safety and Stabilisation skills development in their service provision. These skills are likely to be especially important if someone is using Buprenorphine.

Enablers in the Pathfinder areas

Findings from the TI lens event and the organisational assessment were used to develop an implementation plan alongside management and the TIPIG. Accountability was clear as to who would take the action forward and in what timeframe.

TI Practice implementation was overseen by the Pathfinder TI Practice specialist who was also a Clinical Psychologist. Despite being based remotely and not knowing the teams before the start of the pathfinder, an ‘understanding the service and context’ stage meant they became familiar with service design and pathways, had met staff and spoken to them about their understanding and concerns re implementing TI Practice. This knowledge was then used to tailor the TI lens events for each pathfinder (in relation to the vignettes adopted) and coaching for the team lead. This helped ensure implementation plans were varied and included multiple actions in relation to service design and delivery including changes to physical environments, interactions between staff and people using the service and service pathways.

The TI lens events are also not solely an audit activity but a key mechanism for gaining buy in from staff and those with lived experience of trauma and wider agencies. The events were most successful where sufficient time was given to the exercise; where input was gained from people with lived experience and where other services who regularly collaborated with the drug and alcohol teams were in attendance (for example third sector, Social Work, prisons and GPs). Cross collaboration and opening up the TNA and training plan to these agencies was beneficial and a way of influencing service delivery in other collaborative agencies.

There was evidence of good practice in relation to service delivery in collaborating with GPs and prisons. This included setting up a mailbox for GPs to email queries or concerns; implementing annual reviews by the support team for all patients in shared care; undertaking an initial appointment with practice teams and attending GP cluster meetings to share knowledge about the service and help engage numerous practice teams. The value of attending regular team meetings with prisons was also recognised and working more closely with throughcare teams.

There were examples of joint working between the CMHT and drug and alcohol teams, however this was not always feasible. Improving working collaborations with pharmacy was also identified as an area of priority.

As a result of findings from the TI lens event, two documents were co-produced with people who have lived and living experience of trauma, a ‘This is me’ document and a communications document. The ‘This is Me’ document was based on similar documents used for people using dementia services to support person-centred care. This is used to record details about a person who may find it hard to share information about themselves (for whatever reason) and may include a person’s cultural and family background; important events/people/places in their life and their challenges and existing coping strategies. If a service chooses, this tool may also be used as a way of recording an individual’s trauma and ensuring this is shared with healthcare professionals, so individuals do not have to keep recounting their trauma (if they do not have another document which already meets this need).

The communications document outlined the service pathway, timings, as well as key challenges being faced by the service and how these were being addressed, to help manage expectations of service delivery.

Pathfinder Recommendations relating to Service Design and Delivery

• Wherever possible, whoever is driving the implementation of TI Practice should have knowledge of the team, to facilitate some of the potentially difficult conversations and reflections which may need to happen to implement TI Practice. Without this, the implementation plan may not go into the necessary depth for thorough TI Practice planning. Staff working in collaborative agencies should also be invited to the TI lens event, and to participate in any subsequent TNA and training plans.
• Often facilities management are involved in placing services in suitable buildings. Trauma training should be given to facilities management staff to ensure they understand the importance of physical environment for staff and people using a service.
• Consideration could be given by other addictions services in Scotland as to whether they would find using the ‘This is me’ document and/or the communications leaflet produced in this project useful to further implement TI principles.
• The use of abstinence criteria to access psychology for people who use drug and alcohol as a coping strategy for trauma reactions should be reviewed. Information could also be disseminated about Buprenorphine, emotional clarity and trauma symptoms, and the importance of accessing phase 1 Trauma Treatment (Safety and Stabilisation) for these people.
• Specialist knowledge of trauma reactions and TI Practice needs to also be available to addictions teams to help the teams navigate implementation plans in relation to screening for trauma, clinical supervision, implementing Safety and Stabilisation, and assessing the need for further trauma focussed work if necessary.