There is a significant gap in training on trauma-informed care and routine enquiry into trauma for mental health practitioners in England (McNally et al., 2023). Best practice suggests that training should be provided by mental health trusts in England and co-produced with individuals who have lived experience of trauma (Trevillion et al., 2022). The purpose of this paper is to explore whether co-produced routine trauma enquiry training increases staff confidence within secondary mental health services.
This paper used a mixed-method evaluation, which included brief questionnaires administered before and after the intervention, as well as at a two-month follow-up period, to assess staff confidence and knowledge and whether these were sustained over time. Participants were also interviewed using a semi-structured approach, and the data were analysed using framework analysis.
The intervention improved knowledge in several areas: when to ask about trauma, how to ask, how to respond to a disclosure, how to bring the person back to baseline (within their window of tolerance) and how professionals can care for themselves following a disclosure. Participants reported that the co-produced training increased their confidence in these areas. The intervention benefited all participants, enhancing self-confidence in asking about trauma in a trauma-informed way (routine trauma enquiry), with this increased confidence sustained over the follow-up period. Participants unanimously felt that this training should be mandatory for all staff. One emerging theme highlighted the importance of the service user’s perspective and the powerful impact participants found it to have.
This paper demonstrates the importance of trauma-informed routine trauma enquiry training for mental health staff. It also has implications for future research, as further studies may be needed to explore why trauma-informed care and approaches are not being implemented, by analysing the views of both clinical mental health practitioners and key informants.
This paper advances the research on trauma-informed care and its implementation in secondary mental health services in England.
Introduction
There has been growing interest in trauma-informed care for many years (Berliner and Kolko, 2016; Purtle, 2020), and there is increasing evidence supporting the need for trauma-informed approaches in secondary mental health services (Champine et al., 2019). This is due to the indisputable links between trauma/abuse and mental health issues that typically require support from community mental health teams (CMHTs) or secondary mental health services in the UK. Existing research highlights the connections between trauma and diagnoses such as psychosis (Varese et al., 2012), bipolar disorder (Palmier-Claus et al., 2016) and borderline/emotionally unstable personality disorder (Porter et al., 2019). Trauma has been defined in various ways, but for the purpose of this paper, the Substance Abuse and Mental Health Services Administration’s 2014 definition is used:
Individual trauma results from an event, series of events, or set of 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 well-being. (Huang et al., 2014, p. 7)
Trauma-informed care has developed from a more comprehensive understanding of trauma. The six pillars of trauma-informed care are: safety, empowerment (including choice), trustworthiness and transparency, collaboration, peer support and intersectionality (Huang et al., 2014). Extensive research has found that experiencing four or more adverse childhood experiences can lead to worse physical and mental health outcomes in adulthood (Boullier and Blair, 2018).
Exploring childhood adversity, trauma and abuse has been a debated topic, with some researchers questioning whether exploring abuse with individuals who have mental health issues may be harmful or re-traumatising (Young et al., 2001). However, further research has found routine trauma enquiry to be therapeutic and beneficial for those accessing mental health services (Becker-Blease and Freyd, 2006; Scott et al., 2015). In 2008, health policy guidance recommended that the exploration of abuse and trauma should be attempted and recorded at every access to secondary mental health services and during care planning in the ‘care programme approach’ (CPA), and that this should be undertaken by a “suitably trained professional” (Department of Health, 2008, p. 25). Despite these recommendations, Emsley et al. (2022) found there to be no UK-wide funding commitment or strategy around trauma-informed care.
Recent research suggests that routine trauma enquiry for individuals experiencing severe mental health difficulties or distress continues to be neglected (Read et al., 2018a; Brooker et al., 2020). Brooker et al. (2020) used data from a freedom of information (FOI) request to explore compliance with the Department of Health (2008) recommendations. The authors found that only 12.9% of the 53 mental health trusts (MHTs) surveyed audited the routine enquiry of past abuse or trauma and only 17% of patients were asked any questions about trauma or abuse as part of their CPA assessments. Additionally, many trusts reported inadequate staff training on how to introduce trauma enquiry and respond sensitively to trauma or abuse disclosures. This can lead to staff re-traumatising patients by asking about past trauma in a non-trauma-informed way. While routine trauma enquiry is not the only method to be trauma-informed, it remains of significant importance.
Read et al. (2006, 2007, 2018a, 2018b) conducted research to explore the current levels of routine trauma enquiry in mental health services. The authors found significant evidence that individuals diagnosed with psychosis were less likely to be included in routine trauma enquiry (Read et al., 2018a; Neill and Read, 2022), despite the well-documented links between psychosis and trauma (Varese et al., 2012). They also found that when a disclosure of trauma or abuse was made to a mental health professional, it was not connected to the individual’s treatment plan. Read et al. (2018b) discovered that due to the lack of trauma history enquiries referral rates to therapy were lower for those without documented abuse records. Additionally, the authors found that when abuse histories were recorded in patients’ notes, they were not integrated into the understanding of the patient’s distress or mental health condition. Even when practitioners directly asked about abuse histories, patients who reported abuse were often still not referred for trauma treatment or therapy.
It is therefore necessary to explore the barriers that may prevent trauma from being addressed as part of routine assessments – such as CPA assessments – in individuals with mental health conditions. Research has identified several barriers, including lack of training, fears of opening up a can of worms, and low staff confidence in responding to disclosures (Read et al., 2007). The responding effectively to violence and abuse study (Scott et al., 2015) demonstrated that staff often underestimated the therapeutic value of asking patients about past adverse experiences. This contrasts sharply with qualitative findings from individuals with complex mental health needs, who overwhelmingly welcomed exploration of adversity during assessments; they reported feeling listened to, heard and validated (Scott et al., 2015). People with lived experience of trauma and mental health difficulties viewed the enquiry as helpful, even if they chose not to disclose any abuse or past trauma. Trauma enquiry was seen as positive and important, whereas not being asked was experienced as damaging and dismissive. Therefore, there is a crucial need to support CMHTs and secondary mental health services staff in enhancing their confidence to ensure they feel well-equipped to routinely enquire about trauma and provide support following any disclosures of abuse. Previous research has highlighted the need for training mental health staff in this area (Read et al., 2006), emphasising that identifying abuse is important for both the formulation of presenting issues and the development of treatment plans. More recent findings on routine trauma enquiry in substance use have shown that healthcare professionals can build trauma enquiry and response skills within a short training session (Lotzin et al., 2018).
Despite trauma-informed care and practice gaining international traction over the past two decades (Purtle, 2020), the current level of available training for staff remains limited (McNally et al., 2023). Although the recommendation for routine trauma enquiry has existed for several years (Department of Health, 2008), the training available for staff continues to be limited or even non-existent. Neill and Read (2022) reviewed clinical records to explore routine trauma enquiry in community mental health services in England and found only 1% of clients had been asked about this. They recommended the need for training in the move towards services becoming more trauma-informed. McNally et al. (2023) conducted an FOI request to 52 MHTs in England and found that over 70% of those who responded (40) failed to provide any trauma-related training for their staff and even fewer provided training on routine trauma enquiry. This highlights a significant gap in this area and underscores the need to develop and test training on routine trauma enquiry for MHTs to adopt. Trevillion et al. (2022) emphasised the importance of co-production in the development and improvement of secondary mental health services. Co-production is an approach that involves sharing information, power and resources with people who have lived experience to promote knowledge and develop services. It is now considered best practice for services, research and development efforts. Albert et al. (2023, p. 840) outlined nine core principles of co-production:
power should be shared;
embrace a wide range of perspectives and skills;
respect and value “lived experience” and how different forms of knowledge can be expressed;
ensure that there are benefits to all parties involved in co-production activities;
go to communities. Do not expect people to come to you;
work flexibly;
avoid jargon and ensure communities have access to the right information at the right time;
relationships with communities should be built for the long term; and
make sure co-production initiatives are adequately resourced.
There is a need to explore whether co-produced training around the routine trauma enquiry by people with lived experience of trauma or abuse and of secondary mental health services increases staff confidence and skills in this area.
The principal aim of this study is to evaluate the effectiveness of a synchronised training programme, co-produced with individuals who have lived experience of trauma and mental health difficulties. The goal is to assess whether this training impacts the confidence levels of CMHT and secondary mental health services staff and to explore their perspectives on how well-equipped they feel to routinely enquire about trauma and support individuals following any disclosures of abuse or trauma. To this end, the study evaluates the training and explores the challenges and barriers to routine trauma enquiry, as well as the confidence levels of mental health practitioners.
Method
Ethical approval was granted by the Health Research Authority (307510). A mixed-methods evaluation was undertaken to assess the co-produced training module. Initially, an audit of compliance with CPA routine trauma enquiry for the previous two years was conducted to establish a baseline across the MHT. This data was compiled through the MHT’s business intelligence report. The figures regarding routine trauma enquiry conducted by the teams were monitored for the subsequent two months to identify any significant impact of the training using descriptive quantitative analyses (e.g. percentage increase in CPA assessments incorporating trauma enquiry).
Co-production involves collaborating with individuals who have lived experience of mental health needs, along with their carers, in the planning, commissioning, design and delivery of services. It is a crucial approach for ensuring user involvement and addressing the needs of the “whole person” (Norton, 2024). For this intervention, a co-produced training module was co-developed in collaboration with individuals who have lived experience of abuse, trauma and mental health services. This process took place over several months and involved multiple workshops with people with lived experience from the psychosis research unit infrastructure. The group included individuals currently receiving services, those previously under services, peer support workers, mental health professionals and carers.
Participants were invited to complete the training intervention, which was co-delivered by an individual with lived experience, referred to here as a “lived experience consultant”. The training covered several topics aimed at improving staff knowledge to implement routine trauma enquiry in a trauma-informed manner. The topics included when to ask about trauma (and when not to), how to ask (routine trauma enquiry), how to respond to a disclosure of trauma or abuse, how to bring the person back to their baseline within their window of tolerance (Hersher et al., 2021) and how professionals can care for themselves following disclosure of trauma or abuse. All of these aspects focused on conducting routine trauma enquiry through a trauma-informed lens. The training was delivered over two face-to-face sessions.
Qualified community mental health practitioners are professionals such as community psychiatric nurses, social workers or occupational therapists working in community or secondary mental health services. Participants were recruited using voluntary response sampling from two CMHTs, consisting of around 35 qualified staff members. Thirteen participants agreed to take part in the study and gave consent for their data to be used in research. One participant was excluded because they worked in an urgent crisis service, making the intervention unsuited to their role. The remaining 12 participants were included in the study.
Participants were asked to complete a brief questionnaire assessing their confidence and concerns regarding trauma enquiry (adapted from previous research, e.g. Read et al., 2007). The questionnaire was completed before the training intervention, immediately after the intervention and at a two-month follow-up (see Table 1 below).
Training effectiveness questionnaire
| Following the training, I think the barriers to me asking about trauma, abuse and adverse childhood experiences are: | Strongly disagree | Strongly agree | ||||
|---|---|---|---|---|---|---|
| I feel uncomfortable when asking about traumatic events | 1 | 2 | 3 | 4 | 5 | 6 |
| I have fear of offending the client/patient | 1 | 2 | 3 | 4 | 5 | 6 |
| I have fear of retraumatising the client/patient | 1 | 2 | 3 | 4 | 5 | 6 |
| I have fear that the client may terminate the assessment/intervention/treatment | 1 | 2 | 3 | 4 | 5 | 6 |
| I am unsure whether authorities have to be informed when the perpetrator is known | 1 | 2 | 3 | 4 | 5 | 6 |
| I am not sure of trauma specific treatment available in my local area | 1 | 2 | 3 | 4 | 5 | 6 |
| I am not sure what support to offer following the disclosure | 1 | 2 | 3 | 4 | 5 | 6 |
| I now: | ||||||
| Routinely enquire about past trauma, abuse and adverse childhood experiences with all of my clients | 1 | 2 | 3 | 4 | 5 | 6 |
| Feel confident in asking about past trauma, adverse childhood experiences and abuse | 1 | 2 | 3 | 4 | 5 | 6 |
| Feel confident in my ability to respond to disclosures of abuse and trauma | 1 | 2 | 3 | 4 | 5 | 6 |
| Programme components | ||||||
| I benefitted from the training | 1 | 2 | 3 | 4 | 5 | 6 |
| The training improved my confidence in routinely inquiring about abuse and past trauma with my clients | 1 | 2 | 3 | 4 | 5 | 6 |
| The training increased my confidence in my ability to respond to disclosures of abuse and trauma | 1 | 2 | 3 | 4 | 5 | 6 |
| How would you rate the following sections of the training for your learning: | Not useful at all | Extremely useful | ||||
| Background | 1 | 2 | 3 | 4 | 5 | 6 |
| Barriers of routine enquiry | 1 | 2 | 3 | 4 | 5 | 6 |
| Importance of routine enquiry | 1 | 2 | 3 | 4 | 5 | 6 |
| How to ask about trauma or abuse | 1 | 2 | 3 | 4 | 5 | 6 |
| How to respond to a disclosure of abuse, trauma or adverse childhood experiences | 1 | 2 | 3 | 4 | 5 | 6 |
| Other (please state) | ||||||
| 1 | 2 | 3 | 4 | 5 | 6 | |
| Any other comments | ||||||
| Following the training, I think the barriers to me asking about trauma, abuse and adverse childhood experiences are: | Strongly | Strongly | ||||
|---|---|---|---|---|---|---|
| I feel uncomfortable when asking about traumatic events | 1 | 2 | 3 | 4 | 5 | 6 |
| I have fear of offending the client/patient | 1 | 2 | 3 | 4 | 5 | 6 |
| I have fear of retraumatising the client/patient | 1 | 2 | 3 | 4 | 5 | 6 |
| I have fear that the client may terminate the assessment/intervention/treatment | 1 | 2 | 3 | 4 | 5 | 6 |
| I am unsure whether authorities have to be informed when the perpetrator is known | 1 | 2 | 3 | 4 | 5 | 6 |
| I am not sure of trauma specific treatment available in my local area | 1 | 2 | 3 | 4 | 5 | 6 |
| I am not sure what support to offer following the disclosure | 1 | 2 | 3 | 4 | 5 | 6 |
| I now: | ||||||
| Routinely enquire about past trauma, abuse and adverse childhood experiences with all of my clients | 1 | 2 | 3 | 4 | 5 | 6 |
| Feel confident in asking about past trauma, adverse childhood experiences and abuse | 1 | 2 | 3 | 4 | 5 | 6 |
| Feel confident in my ability to respond to disclosures of abuse and trauma | 1 | 2 | 3 | 4 | 5 | 6 |
| Programme components | ||||||
| I benefitted from the training | 1 | 2 | 3 | 4 | 5 | 6 |
| The training improved my confidence in routinely inquiring about abuse and past trauma with my clients | 1 | 2 | 3 | 4 | 5 | 6 |
| The training increased my confidence in my ability to respond to disclosures of abuse and trauma | 1 | 2 | 3 | 4 | 5 | 6 |
| How would you rate the following sections of the training for your learning: | Not useful | Extremely | ||||
| Background | 1 | 2 | 3 | 4 | 5 | 6 |
| Barriers of routine enquiry | 1 | 2 | 3 | 4 | 5 | 6 |
| Importance of routine enquiry | 1 | 2 | 3 | 4 | 5 | 6 |
| How to ask about trauma or abuse | 1 | 2 | 3 | 4 | 5 | 6 |
| How to respond to a disclosure of abuse, trauma or adverse childhood experiences | 1 | 2 | 3 | 4 | 5 | 6 |
| Other (please state) | ||||||
| 1 | 2 | 3 | 4 | 5 | 6 | |
| Any other comments | ||||||
After the intervention, all participants (n = 12) were invited to a semi-structured interview to explore their views and evaluate the intervention. The criteria for reporting qualitative research, as outlined by Tong et al. (2007), were followed. The interviews were conducted and facilitated by two authors of this paper, who are female and have a prior interest in trauma research and experience working in the mental health field. Each interview was audio-recorded and stored in a secure cyber location. The recordings were transcribed and analysed using framework analysis with a systematic approach (Ritchie and Spencer, 1994).
To analyse the interviews, open coding was used using an inductive approach. Codes were generated, and the researchers iteratively moved between codes and data, revisiting the codes as necessary. Once the codes were consolidated, they were developed into themes, and definitions were created for each theme. The themes were then re-applied to the data using the coding framework. The researchers also searched for disconfirming evidence and noted these findings. A matrix was used to index and map the data. To enhance the rigor of the research, two additional stages were implemented. In the first stage, a second researcher reviewed a sample of the data and independently coded their own themes. In the second stage, the themes, definitions and codes were shared with a third researcher for re-analysis. Interpretations of the themes were examined for interrelationships and overarching explanations in line with current research. Any discrepancies within the coding framework were discussed among the researchers and resolved collaboratively.
Results
Questionnaires
Results from the questionnaires indicated signs of change following the intervention. All participants (n = 12) reported higher levels of confidence and knowledge after the training. These improvements were sustained at the two-month follow-up. Most participants (n = 11) showed a significant and sustained reduction in concerns about the following: “I feel uncomfortable when asking about traumatic events”, “I fear offending the client/patient”, “I have fear of retraumatising the client/patient”, “I have fear that the client may terminate the assessment/intervention/treatment” and “I am unsure what support to offer following a disclosure”. There was, however, a smaller reduction in concerns related to “I am unsure whether authorities need to be informed when the perpetrator is known” and “I am not sure of trauma-specific treatment available in my local area”. This may suggest that the training was less effective in these areas. Most participants (n = 11) felt that the training intervention on trauma-informed care and routine trauma enquiry was relevant and important to their role. It helped them feel more confident in conducting routine trauma enquiry and responding to disclosures. The results demonstrated that the training intervention was effective in building confidence and skills, particularly in bringing the patient back to their baseline, using the window of tolerance, and applying the techniques in the provided toolkit.
There was a significant increase in how participants rated their practice at the two-month follow-up period. All participants reported that they now “routinely enquire about past trauma, abuse and adverse childhood experiences with all of my clients”. There was also a sustained improvement in participants’ confidence in “asking about past trauma, adverse childhood experiences and abuse”, which was maintained at the two-month follow-up. Participants reported a significant increase in “feeling confident in my ability to respond to disclosures of abuse and trauma”, both immediately after the training and at the follow-up period. All participants indicated that they felt they benefited from the training, and this opinion was consistent at the follow-up.
Business intelligence reports
The analysis of the baseline figures for the two years prior to the intervention and following the intervention showed no significant effects or changes. This lack of significant findings is likely due to the small sample size (n = 12). Further research with a larger sample size is needed to accurately assess the impact of the intervention on the audit baseline numbers.
Interviews
Following the training intervention, participants were interviewed and researchers coded and collated themes from these interviews. The identified themes that appeared were:
lack of prior knowledge or training;
staff anxieties;
increase in confidence;
implications for future practice;
co-production;
opening the door; and
recommended for others.
Each theme was defined, and the definitions were reviewed by the other researchers. The definitions of each theme are documented in Table 2 below.
Definitions of themes
| Definitions | |
|---|---|
| Theme 1: | Lack of prior knowledge or training |
| A participant’s lack of existing information and understanding around trauma informed care and the routine enquiry into trauma or abuse. Including a lack of formal training in this area, prior to the intervention | |
| Theme 2: | Staff anxieties |
| Mental health professional’s worries or fears around approaching the subject of trauma or abuse with patients | |
| Theme 3: | Increase in confidence |
| An enhancement in how the staff member feels about their own abilities around approaching the subject of trauma or abuse with patients | |
| Theme 4: | Implications in future practice |
| Mental health professional’s views around their ability to use the knowledge, materials and resources learnt, within their own practice with service users and patients, following the training | |
| Theme 5: | Co-production |
| Intervention developed with lived experience consultants. A sense of being in the service user’s shoes and a focus on their perspective | |
| Theme 6: | Opening the door |
| Creating safe communication between mental health professionals and service users/patients around trauma or abuse | |
| Theme 7: | Recommended for others |
| The training intervention would be beneficial for other colleagues |
| Definitions | |
|---|---|
| Theme 1: | Lack of prior knowledge or training |
| A participant’s lack of existing information and understanding around trauma informed care and the routine enquiry into trauma or abuse. Including a lack of formal training in this area, prior to the intervention | |
| Theme 2: | Staff anxieties |
| Mental health professional’s worries or fears around approaching the subject of trauma or abuse with patients | |
| Theme 3: | Increase in confidence |
| An enhancement in how the staff member feels about their own abilities around approaching the subject of trauma or abuse with patients | |
| Theme 4: | Implications in future practice |
| Mental health professional’s views around their ability to use the knowledge, materials and resources learnt, within their own practice with service users and patients, following the training | |
| Theme 5: | Co-production |
| Intervention developed with lived experience consultants. A sense of being in the service user’s shoes and a focus on their perspective | |
| Theme 6: | Opening the door |
| Creating safe communication between mental health professionals and service users/patients around trauma or abuse | |
| Theme 7: | Recommended for others |
| The training intervention would be beneficial for other colleagues |
Theme 1.
Theme 1 is “A lack of prior training or knowledge”, defined as “A participant’s lack of existing information and understanding about trauma-informed care and the routine enquiry into trauma or abuse, including a lack of formal training in this area prior to the intervention”. All participants (12) contributed to this theme. Quotes from this theme included: “I don’t even know if I had heard of trauma-informed care”, “I hadn’t received any training at all in trauma-informed care” and “No, I’ve never heard of it before”. Participants also stated things like: “I did not know what it was before”, “I wasn’t 100% sure what routine trauma enquiry was” and “No, I never had any specific training about asking about trauma”.
Theme 2.
Theme 2 is labelled “Staff anxieties”, defined as “Mental health professional’s worries or fears about approaching the subject of trauma or abuse with patients”. Ten participants’ quotes contributed to this theme, their quotes included: “I can be really nervous”, “there is an aspect of uncomfortability”, “I felt a bit apprehensive” and “I’ve always felt awkward about it [asking about trauma]”.
Theme 3.
The third theme was “Increase in confidence”, characterised as “An enhancement in how the staff member feels about their own abilities to approach the subject of trauma or abuse with patients”. Here, nine participants contributed to this theme and they stated: “I definitely feel more confident”, “I feel a lot more secure about dealing with a disclosure”, “The training has given me the information needed to confidently ask those questions” and “I feel 100% better about it”.
Theme 4.
The next theme was “Implications for future practice”, outlined as “Mental health professional’s views on their ability to apply the knowledge, materials and resources learnt in their own practice with service users and patients following the training”. Nine out of 12 participants contributed to this theme. Quotes in this area included: “I’m going to refer to it [the toolkit] quite a lot”, “The different techniques people can use were helpful, as well as the numbers they can call”, “It has moved from a tick-box exercise to an actual therapeutic intervention” and “The toolkit was a really good idea […] it’s really helpful to have everything together, particularly in difficult situations”. Participants appreciated having practical techniques in the toolkit for their future practice. One participant suggested having one technique per page for ease, so they could photocopy and share it with clients and patients. Some participants reported finding the skills-based learning task (the role play) challenging during the training. However, despite this, they still found it an effective way to develop skills for practice.
Theme 5.
Theme 5 was named “Co-production”, defined in this instance as “An intervention developed with lived experience consultants, providing a sense of being in the service user’s shoes and focusing on their perspective”. Nine participants contributed to this theme and throughout the interviews, participants stated things such as: “It is nice to see the quotes and hear what those people thought”, “The service user perspective was the whole take away of the training”, “I think that lived experience is the most important element of any training […] listening to that”, “That’s what the service users want” and “The lived experience part of the training and having that as a theme throughout is definitely something different”.
Theme 6.
Theme 6 was named “Opening the door” and defined as “Creating safe communication between mental health professionals and service users/patients around trauma or abuse”. This theme recurred throughout the interviews with seven participants. They mentioned points such as: “Create an environment that’s safe”, “Gives them that control and empowers them to be able to tell practitioners what to do for people in the future to best help them”, “To get a better understanding of what has brought you to the table”, “It’s human contact; it’s a conversation, it’s listening, it’s reflecting, it’s paraphrasing” and “I think it’s important, as it might open the door”.
Theme 7.
The final theme collated was “Recommended for others”, this was defined as “The training intervention would be beneficial for other colleagues”. This theme highlighted that participants felt that the intervention was helpful and would also be useful for their colleagues. There was a mix of opinions within this theme, with some participants believing that the training should be mandatory for their colleagues or at least offered as an elective training option. However, all 12 participants agreed it should be offered to staff. Quotes included: “It was really insightful”, “I think it should be offered to the whole Trust for people to elect to take it”, “I didn’t realise I would get so much from it” and “We can incorporate it into the new starters” training and make it part of the mandatory training”. One mental health practitioner noted: “After working as a care coordinator for 15 years, I’ve never come across anything that’s been as beneficial in terms of developing your own practice”.
Discussion
An important area to highlight is that over 90% (n = 11) of the participants reported having received limited or no previous training in trauma-informed care or trauma-informed approaches prior to this intervention. Despite trauma-informed care being a focus for mental health services for over 20 years, most participants in this study had no prior training in this area. Additionally, many participants were unfamiliar with the concept of “routine trauma enquiry”. This is consistent with findings obtained by McNally et al. (2023), which revealed that most MHTs in England have not been providing any training in this area for their staff. It also links in with other previous research which states that one main barrier to implementing trauma-informed interventions is a lack of a coherent understanding alongside structural support and a safe space (Chadwick and Billings, 2022).
The findings of the present study reinforce the existing literature on staff anxieties related to trauma (Read et al., 2006, 2007; Scott et al., 2015). Read et al. (2007) observed that staff often worried about opening up a can of worms, a concern echoed in this study. Most participants reported feeling anxious or fearful about addressing trauma prior to the training. Staff anxieties emerged as a significant theme, with participants expressing discomfort, apprehension and nervousness, despite being experienced qualified mental health professionals (nurses, social workers and occupational therapists). This apprehension may have affected their practice. Ignoring the topic of trauma has been shown to be invalidating for patients and can increase stigma (Scott et al., 2015). Therefore, enhancing staff knowledge, skills and confidence in this area is crucial. This aligns with previous research indicating that training programmes can boost professionals’ confidence (Read et al., 2007; Lotzin et al., 2018).
Another key finding from the study is the significance of incorporating lived experience voices and narratives. This research builds on existing evidence (Trevillion et al., 2022) by demonstrating the effectiveness of integrating lived experience into the development of the training. Participants highlighted that the lived experience perspective was instrumental in deepening their understanding of the service user’s viewpoint, describing it as the most powerful and valuable aspect of the intervention. They also noted that the co-produced training had practical implications for their practice, providing both skills and knowledge that enhanced their confidence. One participant remarked that the training transformed the “routine trauma enquiry” from a mere procedural task (a tickbox exercise) into a meaningful therapeutic intervention. Additionally, many found the toolkit to be a clear and accessible resource that they could easily integrate into their practice.
The framework analysis identified that “opening the door” for a service user to discuss their trauma history in a safe space was a recurring theme in the interviews. Participants made statements such as, “it’s giving someone an opportunity in a safe space”, “create an environment that’s safe”, “being asked the question is validating”, “it isn’t this big elephant in the room that they need to worry about telling you or not telling you or asking you about” and “they can choose how much to disclose”. These comments illustrate how participants’ perspectives shifted regarding the importance of routine trauma enquiry, moving from initial anxieties about asking to recognising its significance. The results of this project showed that all participants recommended delivering this training to all mental health professionals (n = 12).
Participants provided the following feedback: “The training was really insightful” and “After working as a care coordinator for 15 years, I’ve never come across anything as beneficial in terms of developing your own practice”. This research also recommends that all mental health professionals, across various settings in secondary mental health services, should receive mandatory training on trauma, abuse and adversities to enhance their trauma responsiveness and trauma-informed practice. Participants suggested: “It could be incorporated into the mandatory part of training”, “I would recommend it to external providers as well, not just people within secondary mental health services” and “I think it should be offered to the whole Trust for people to elect to take it”. Some participants highlighted specific elements of the training that they found particularly useful, such as: “The toolkit is definitely something that I will use going forward in visits and when seeing people”, which is expected to impact their future practice.
The limitations of this study include the small sample size (n = 12). Future research should aim to scale up the study to a larger population to better assess the significance of the impact. It would also be helpful to widen the follow-up period time to explore the sustainability of the improvements over a longer time period. Additionally, the method of recruiting participants through voluntary sampling may have introduced self-selection bias. Further research is needed to evaluate how, and if, the routine trauma enquiry is conducted in a trauma-informed manner, from both professional and service user perspectives.
It may also be valuable to explore why trauma-informed care and approaches are not being more widely implemented by analysing the perspectives of both clinical mental health practitioners and key informants. The results of this study indicate that mental health professionals who participated in receiving the co-produced and co-delivered training benefited in several ways. The intervention enhanced staff confidence and reduced anxieties regarding routine trauma enquiry, increased knowledge in this area and developed skills-based learning with practical implications. Most importantly, it amplified the service user’s voice by incorporating their perspective. This project also highlights the need for organisations to further advance their efforts to improve services related to trauma-informed care and approaches.
The question remains: if trusts are not providing routine trauma enquiry training, are they continuing to re-traumatise patients? The next steps could involve examining implementation science related to trauma-informed care to thoroughly explore the barriers to its adoption in secondary mental health settings. Additionally, investigating the perspectives of both professionals and service users on whether routine trauma enquiry is conducted in a trauma-informed manner following this training would be a valuable extension of this research. Finally, evaluating this training from a service user perspective around their views of any improvement in the care they receive would be beneficial in moving services forward.
This research paper was developed and co-authored with lived experience consultants of trauma, abuse, adversities and secondary mental health services. This paper is funded by the National Institute for Health and Care Research (NIHR) Applied Research Collaboration Greater Manchester (ARC-GM) pre-doctoral fellowship. The views expressed in this publication are those of the author(s) and not necessarily those of the National Institute for Health and Care Research or the Department of Health and Social Care.
Declaration of interests: No known conflicts of interest are associated with this research.
