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The pros and cons of implementing trauma informed care in Danish psychiatry

Authors:
Jesper Bak
Jesper Bak
Jacob Hvidhjelm at Region Hovedstaden
Jacob Hvidhjelm
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Abstract and Figures

Background: principals of trauma informed care are implemented at many mental health hospitals across the US. In Denmark there are no such principals implemented. That might be because patients and staff do not experience trauma to the same extent as in the US. The OECDs social indicators ranked Denmark in top, with a score on safety at 9.5, and life satisfaction on 9.7 on a scale from 0 to 10. The US is ranked much lower, with a safety score on 7.5, and life satisfaction on 7.3. Objectives: this study explores to what extent patients and staff in Denmark, has been exposed to traumatic experiences earlier in life, compared to patients and staff in us. Methods: a cross sectional survey on trauma experiences among patients admitted to a psychiatric ward and staff-members working at a psychiatric ward, using the brief trauma questionnaire (BTQ) will be conducted. The results will be compared to figures from the US. Results: results from the surveys will be presented at the congress. Conclusions: conclusions from the survey will be presented at the congress. Discussion: a discussion on method, results, and conclusions in relation to implementing trauma informed care and in relation to other important issues for the mental health community e.g. patient involvement, recovery, and the “Six Core Strategy” to prevent coercion, will be addressed.
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125
Chapter 5 – Trauma informed care &
practice
The pros and cons of implementing trauma
informed care in Danish psychiatry
Paper
Jesper Bak & Jacob Hvidhjelm (Denmark)
Keywords: Mental health, nursing, trauma, trauma informed care
Introduction
Trauma informed care could be dened as: A strengths-based service delivery approach that is
grounded in an understanding of and responsiveness to the impact of trauma, that emphasizes physical,
psychological, and emotional safety for both providers and survivors, and that creates opportunities for
survivors to rebuild a sense of control and empowerment
Background
Principals of Trauma Informed Care (TIC) are implemented at many mental health hospitals across the
US. In Denmark there are no such principals implemented. That might be because patients and staff
don’t experience trauma to the same extent as in the US. The OECDs social indicators ranked Denmark
in top with a score on safety at 85% (safe walking alone at night), and life satisfaction on 7.5 on a scale
from 0 to 10. The US is ranked lower, with a safety score on 74%, and life satisfaction on 6.9 (2).
Objectives
This study explores to what extent patients and staff in Denmark, has been exposed to traumatic
experiences earlier in life, compared to patients and staff in US.
Methods
A cross sectional survey on trauma experiences among patients admitted to a psychiatric ward and
staff-members working at two psychiatric wards (one forensic and one dual-diagnostic), using the Brief
Trauma Questionnaire (BTQ) (3) were conducted. The BTQ was translated to Danish, back translated
to English, compared and revised accordantly, by the two authors. The questionnaire was distributed
electronically, using Enalyzer (4), and handled anonymously, so that the researchers were blinded
to who the respondent were. All analyses were performed using IBM SPSS Statistics for Windows,
Version 22.0 (Released 2013; IBM Corp., Armonk, NY).
126
Results
The sex distribution of the respondent showed 27% were men, the average age was between 41
and 50 years, the education was distributed with 44% nurses aids, 31% nurses, 12% psychologists/
psychiatrists, and 13% others, and the response rate was 69.4% (respondents, N=309).
Table 1. Distribution of traumatic life events among staff in two mental health wards in Denmark
Traumatic life events (N=309) %(n)
1. Experiencing war (life in danger/seriously injured) 2(5)
2. Serious accident (life in danger/seriously injured) 23 (70)
3. Natural or technological disaster (life in danger/seriously injured) 6(17)
4. Life threatening disease (life in danger/seriously injured) 7(23)
5. Childhood trauma (physically punished or beaten - life in danger/seriously injured) 8(26)
6. Childhood trauma (attacked, beaten or bullied - life in danger/seriously injured) 22 (68)
7. Unwanted sexual contact (life in danger/seriously injured) 4(13)
8. Seriously injured (seriously injured) 7(20)
9. Close persons death after a violent incident 20 (62)
10. Witnessed other person seriously injured or killed 25 (76)
At least one incident 63.7 (197)
At least two incidents 34.3 (106)
At least three incidents 16.8 (52)
At least four incidents 6.1 (19)
At least five incidents 1.6 (5)
Six incidents 0.3 (1)
Note. Descriptive statistics of traumatic life events. N = number of all respondents. % = percent of
respondents in the group. n = number of respondents in the group.
Table 1, the most common traumatic life event was “Witnessed other person seriously injured or killed”
25%, the next was “Serious accident (life in danger/seriously injured)” 23%, followed by “Childhood
trauma (attacked, beaten or bullied - life in danger/seriously injured)” 22%. Regarding the number of
traumatic life events, 64% of the staff members had experienced at least one traumatic life event, 34%
at least two events, 17% at least three events, 6% at least four events, 2% at least ve events, and last
0.3% equal to one person six events, out of ten possible events.
Table 2. Associations between traumatic life events and background variables
Background variables B95% CIs of B p
Ward (forensic ward vs. dual-diagnostic ward) 0.10 [-0.24, 0.45] .55
Sex (male vs. female) -0.23 [-0.59, 0.14] .23
Age (five, 10 years groups) -0.07 [-0.20, 0.07] .31
Education (nursing aids/nurses vs. psychologists/psychiatrists) -0.61 [-1.08, -0.15] .01
Note. The parameters (B) were estimated using a linear regression, and all background variables
were analysed together. The parameters should be interpreted as, e.g. education; there is a difference
between the two groups of 0.6 traumatic life events in average.
127
Table 2, the only background variable signicantly associated with number of traumatic life events was
education. We found higher educated staff (psychologists and psychiatrists), in average had experienced
fewer traumatic life events (B = -0.61, p = .01).
Preliminary results from the survey where the respondents were patients with a dual-diagnostic
diagnose will be presented at the congress.
Conclusions
Quit a large amount of the staff had experienced traumatic life events, and a few had experienced
several.
Conclusions from the patient survey will be presented at the congress.
Discussion
The use of BTQ to collect data on traumatic life events was chosen because it is brief, and easily
understood by respondents. Schnurr (5), found Kappa coefcients for the presence of trauma that met
DSM criterion A1 were above .70 (range .74-1.00) for all events, except for disease (.69) and “other
persons seriously injured or killed” (.60). So the BTQ would nd trauma in a good or almost perfect
way.
Using an electronical system (Enalyzer) to collect the questionnaires, which was able to hide the
identity of the respondents to the researchers, could be one of the reasons why so many answered
the very private and sensitive questions, and thereby strengthen the representativeness of the study.
The response rate of 69.4% would in many cases be described as acceptable (6), and the likelihood of
response bias rather low.
The amount of staff that experienced traumatic life events was not very different from earlier ndings
of population samples in the US, Kessler (7) found 56%, and Breslau (8) found 61% had experienced at
least one traumatic life event. Also, the level of education has been found earlier to be associated with
the number of traumatic life events (9). So even though we score higher on safety, and life satisfaction,
on the OECDs social indicators, this seems not to be connected to experiencing lesser traumatic life
events.
It seems that we can (before we know how many traumatic life events the patients experience) deduce,
that it is not because the staffs in Denmark experiences fewer traumatic life events, that we have not
implemented principals of TIC. And because the amount of traumatic life events is as high as in the
US, it is an area we as staff (and patients) probably should be more interested in, and paying more
attention to.
Acknowledgements
We would like to thank the staff and patients at Mental Health Centre Sct. Hans, for trustingly answer
the questionnaire about trauma-experiences.
References
1. Hopper EK, Bassuk EL, Olivet J. Shelter from the storm: Trauma-informed care in homelessness services settings. The
Open Health Services and Policy Journal 2010;3(2):80-100.
2. Better Life Index. OECD.Stat . 2016. OECD. 17-7-2017. Ref Type: Online Source
3. Schnurr P, Vielhauer M, Weathers F, Findler M. The brief trauma questionnaire. White River Junction, VT: National
Center for PTSD 1999.
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5. Schnurr PP, Spiro A, Vielhauer MJ, Findler MN, Hamblen JL. Trauma in the lives of older men: Findings from the
Normative Aging Study. Journal of Clinical Geropsychology 2002;8(3):175-87.
128
6. Draugalis JR, Coons SJ, Plaza CM. Best practices for survey research reports: a synopsis for authors and reviewers.
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7. Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB. Posttraumatic stress disorder in the National Comorbidity
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8. Breslau N, Chilcoat HD, Kessler RC, Davis GC. Previous exposure to trauma and PTSD effects of subsequent trauma:
results from the Detroit Area Survey of Trauma. American journal of Psychiatry 1999;156(6):902-7.
9. Breslau N, Davis GC, Andreski P, Peterson E. Traumatic events and posttraumatic stress disorder in an urban population
of young adults. Archives of general psychiatry 1991;48(3):216-22.
Correspondence
Jesper Bak: jesper.bak@regionh.dk.
Trauma Informed Care – næste skridt mod en positiv psykiatrikultur der forebygger tvang
Technical Report
Full-text available
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Formålet med denne artikel er at introducere Trauma Informed Care (TIC) til danske sygeplejersker. TIC er tvangsforebyggende og anvendes, ikke kun i psykiatrien, men i forhold til mange forskellige diagnosegrupper rundt om i verden.
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Shelter from the Storm: Trauma-Informed Care in Homelessness Services Settings~!2009-08-20~!2009-09-28~!2010-03-22~!
Article
Full-text available
  • Apr 2010
  • Open Health Serv Pol J
It is reasonable to assume that individuals and families who are homeless have been exposed to trauma. Research has shown that individuals who are homeless are likely to have experienced some form of previous trauma; homelessness itself can be viewed as a traumatic experience; and being homeless increases the risk of further victimization and retraumatization. Historically, homeless service settings have provided care to traumatized people without directly acknowledging or addressing the impact of trauma. As the field advances, providers in homeless service settings are beginning to realize the opportunity that they have to not only respond to the immediate crisis of homelessness, but to also contribute to the longer-term healing of these individuals. Trauma-Informed Care (TIC) offers a framework for providing services to traumatized individuals within a variety of service settings, including homelessness service settings. Although many providers have an emerging awareness of the potential importance of TIC in homeless services, the meaning of TIC remains murky, and the mechanisms for systems change using this framework are poorly defined. This paper explores the evidence base for TIC within homelessness service settings, including a review of quantitative and qualitative studies and other supporting literature. The authors clarify the definition of Trauma-Informed Care, discuss what is known about TIC based on an extensive literature review, review case examples of programs implementing TIC, and discuss implications for practice, programming, policy, and research.
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Posttraumatic Stress Disorder in the National Comorbidity Survey
Article
Full-text available
  • Jan 1996
  • ARCH GEN PSYCHIAT
Data were obtained on the general population epidemiology of DSM-III-R posttraumatic stress disorder (PTSD), including information on estimated life-time prevalence, the kinds of traumas most often associated with PTSD, sociodemographic correlates, the comorbidity of PTSD with other lifetime psychiatric disorders, and the duration of an index episode. Modified versions of the DSM-III-R PTSD module from the Diagnostic Interview Schedule and of the Composite International Diagnostic Interview were administered to a representative national sample of 5877 persons aged 15 to 54 years in the part II subsample of the National Comorbidity Survey. The estimated lifetime prevalence of PTSD is 7.8%. Prevalence is elevated among women and the previously married. The traumas most commonly associated with PTSD are combat exposure and witnessing among men and rape and sexual molestation among women. Posttraumatic stress disorder is strongly comorbid with other lifetime DSM-III-R disorders. Survival analysis shows that more than one third of people with an index episode of PTSD fail to recover even after many years. Posttraumatic stress disorder is more prevalent than previously believed, and is often persistent. Progress in estimating age-at-onset distributions, cohort effects, and the conditional probabilities of PTSD from different types of trauma will require future epidemiologic studies to assess PTSD for all lifetime traumas rather than for only a small number of retrospectively reported "most serious" traumas.
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Previous Exposure to Trauma and PTSD Effects of Subsequent Trauma: Results From the Detroit Area Survey of Trauma
Article
Full-text available
  • Jul 1999
With the exception of a few reports of higher rates of childhood trauma in Vietnam veterans with posttraumatic stress disorder (PTSD), little is known about the influence of previous exposure to trauma on the PTSD effects of subsequent trauma. The authors examine interrelated questions about the effects of previous exposure to trauma. A representative sample of 2,181 individuals in southeast Michigan were interviewed by telephone to record lifetime history of traumatic events specified in DSM-IV as potentially leading to PTSD. PTSD was assessed with respect to a randomly selected index trauma from the list of events reported by each respondent. History of any previous exposure to traumatic events was associated with a greater risk of PTSD from the index trauma. Multiple previous events had a stronger effect than a single previous event. The effect of previous assaultive violence persisted over time with little change. When they examined several features of the previous exposure to trauma, the authors found that subjects who experienced multiple events involving assaultive violence in childhood were more likely to experience PTSD from trauma in adulthood. Furthermore, previous events involving assaultive violence--single or multiple, in childhood or later on--were associated with a higher risk of PTSD in adulthood. Previous exposure to trauma signals a greater risk of PTSD from subsequent trauma. Although these results are consistent with a sensitization hypothesis, like the results from previous research on PTSD, they do not address the mechanism of increased responsivity to trauma. Long-term observational studies can further elucidate these observations.
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Best Practices for Survey Research Reports: A Synopsis for Authors and Reviewers
Article
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  • Mar 2008
  • AM J PHARM EDUC
We have provided 10 guiding questions and recommendations regarding what we consider to be best practices for survey research reports. Although our recommendations are not minimal standards for manuscripts submitted to the Journal, we hope that they provide guidance that will result in an enhancement of the quality of published reports of questionnaire-based survey research. It is important for both researchers/authors and reviewers to seriously consider the rigor that needs to be applied in the design, conduct, and reporting of survey research so that the reported findings credibly reflect the target population and are a true contribution to the scientific literature.
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Trauma in the Lives of Older Men: Findings from the Normative Aging Study
Article
  • Jul 2002
Research on the prevalence of traumatic exposure has tended to focus on younger populations, limiting our knowledge about trauma and its effects in older adults. In this study, lifetime trauma exposure was assessed in a sample of 436 male military veterans of World War II and the Korean Conflict (age 59–92). A clinician-administered screening measure, the Brief Trauma Interview, was developed to assess lifetime exposure to 10 categories of trauma using DSM-IV criteria. PTSD was assessed in interview and questionnaires. Despite a high prevalence of trauma exposure, symptom levels were relatively low. Few men met criteria for current or lifetime PTSD. Secondary analyses found that lifetime symptom severity was higher in men who met the DSM-IV A.2 criterion, in contrast with men who did not meet A.2. Findings indicate that trauma is highly prevalent among older men, although many may be asymptomatic.
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The brief trauma questionnaire. White River Junction, VT: National Center for PTSD
  • Jan 1999
  • P Schnurr
  • M Vielhauer
  • F Weathers
  • M Findler
Schnurr P, Vielhauer M, Weathers F, Findler M. The brief trauma questionnaire. White River Junction, VT: National Center for PTSD 1999.