By Karina Farrell – Mental Health and Wellbeing Practitioner at One Recovery Bucks.

Following the publication of Inclusion’s Trauma Informed Practice Guidance, our services are committed to embed the principles. This article focuses on how trauma-informed practice is applied in our community drug and alcohol services, using the story of a client at One Recovery Bucks.

For confidentiality purposes, the client’s initials and any other identifiable information has been changed.

JS has been a client of One Recovery Bucks (ORB) for quite some time. His story is long and complex. It started over 4 decades ago in Nigeria, where JS was born and lived until he was 15 years old. Between then and 2018, when he first came to ORB for support with alcohol use, JS experienced multiple, significant traumas which later resulted in diagnoses of complex post-traumatic stress disorder and mixed personality disorder.

JS went through homelessness, imprisonment and torture. He was stabbed, shot at and sexually abused. He watched his loved ones die in tragic accidents. This accumulation of horrific, life-changing experiences left him forever stuck in survival mode. Always feeling unsafe, hypervigilant and having a real difficulty in trusting other people. He was overwhelmed with intrusive thoughts about the past, flooded with images he wished he never saw and would wake up in terror multiple times a night. This led to JS being easily angered and getting in trouble with the police and unable to put his exhausted mind to rest by any means, other than binge drinking large amounts of alcohol.

JS was referred to me, a newly qualified and freshly established Mental Health and Wellbeing Practitioner (MHWP), around March 2024. Up until now, it was rare for drug and alcohol services to have a mental health professional within the team. Previously, clients reporting mental health difficulties had to be referred to external community mental health teams or local talking therapies centres. It was (and to some extent, still is) a rather complex system to navigate, both for professionals and clients involved.

When I met JS for the first time, he had already been through many of those doors and appeared to have exhausted most of the support options. He had seen psychiatrists and mental health nurses who offered diagnoses and prescriptions. He had worked with housing officers and councils and was now in secure, appropriate accommodation. With Job Centre’s support, he obtained a number of benefits and no longer had to worry about finances. He has been through detoxes, residential rehabs and community-based drug and alcohol support and was now able to maintain extended periods of abstinence. He had social workers, probation officers and mental health support workers involved in his care. People were coming and going, with a whole web of support agencies coming with different criteria, expectations and procedures; JS managed as best as he could and attended as many appointments as he could. He would tell his story over and over again, even though he did not want to. He got on with some better than with others. But he never gave up, even though some individuals and services gave up on him and closed doors he desperately needed to go through.

On paper, things looked pretty good for JS. A lot of progress has been made and a lot of actions have been ticked off, but that wasn’t his subjective experience. JS was still struggling and battling his demons every day. His intrusive thoughts haven’t stopped, his flashbacks and nightmares continued to torment him and his past traumas were keeping him stuck in the past, making it painfully difficult to move forward.

So what was missing if everything was seemingly already in place?

A few months ago, when JS was first referred to me, I had no answer to this question. I had no idea what I could bring to the table that wasn’t already offered by someone else before me. However, Tom (JS’s Alcohol Recovery Worker) did.

The many years of experience in drug and alcohol services taught Tom what was missing in the care of individuals like JS. What was missing was a model of care based on trauma-informed principles. A holistic and integrative approach which removes barriers and simplifies expectations. Tom was looking for an ally who could help him deliver this and something about me and my role gave him the hope that, working together as a team under the umbrella of the same service, we have a better chance at offering this to JS than he’s ever had when working with external agencies. Six months later, we are starting to see the benefits of trauma-informed care.

What is trauma-informed practice?

Trauma-informed practice (TIP) is a relatively new concept which is only just starting to permeate vocabularies of health and care services in England. It originates from earlier findings that effects of trauma are substantial and long-lasting, often leading to a range of difficulties, including mental wellbeing, physical health, substance use, education, employment and increased contact with Social Work and the Criminal Justice System. A large proportion of individuals coming into contact with public organisations, responsible for the delivery of such services, have gone through traumatic experiences in the course of their lives.

Trauma-informed practice recognises that the effects of trauma manifests in survivors’ neurological, biological, psychological and social developments – affecting a broad range of behaviours. Therefore, these behaviours need to be reframed as potential responses to trauma-related triggers, rather than labelled as anti-social, defiant or offensive.

The key principles of TIP include safety, trustworthiness (transparency), choice, collaboration, empowerment and cultural consideration. And even though TIP does not expect professionals to become trauma specialists or deliver interventions to treat trauma, it argues that organisations and services must create conditions where individuals feel safe, empowered and can develop trusting relationships without judgement and stigma, and where potential for re-traumatisation is minimised. Those principles should be reflected in internal policies and practices of each organisation but also at the multi-agency level of collaboration between individual services, based on a shared understanding of trauma and trauma-informed practice.

What does trauma-informed care look like for individuals like JS?

It started with Tom’s decision to refer JS to an internal mental health professional (me) rather than using an external agency. Tom and I sat down together, he talked me through JS’s story, explained his difficulties and we decided to work on a joint care plan and carry out sessions together. This minimised the risk of re-traumatisation, as JS did not have to go through another assessment and feel pressured to disclose details of his experiences to yet another professional. It also prevented the additional demands of having to attend and manage multiple appointments and to adapt to another set of procedures and expectations. Moreover, it made it easier for JS to develop a trusting relationship with myself, as his distress of meeting me was hopefully mitigated by the feelings of safety associated with Tom’s presence.

We adopted an approach of total transparency by being clear about our roles and their limitations. At all times, JS knew what we were and were not able to offer him. He also knew that eventually, once he’s ready, he will have to transition to an external agency for trauma-specific treatment (we were unable to avoid this as none of us had the correct training). We were honest about this being a difficult and challenging journey, but we also reassured JS that we will support him at all times until he is ready to move on. We explained all his options in detail, ensure he was equipped with knowledge and understanding of his situation and empowered him to choose the path he wanted to follow. With his explicit consent, we collaborated with his partner and other professionals involved. We understood his disengagement and lapses as signs of struggle and opportunities to learn, rather than as excuses to discharge him.

When the time came to involve a trauma-specific service, at JS’s request, we supported him in attending initial appointments and building new relationships. We intervened, advocated and formally complained when other professionals’ standards of practice deviated from trauma-informed principles. Even though JS has now started much-needed intense trauma therapy with a local psychological therapies service, he remains a client of One Recovery Bucks and we continue to check-in with him on a regular basis. I am certain that we made mistakes along the way, but we gave it our best shot.

What we learned from JS’s story

JS’s story illustrates that although we are still making progress towards fully implementing trauma-informed principles, as a society, we still have a lot to learn. In comparison to other professionals previously involved in JS’s care, I was lucky.

I have only just started working in the field and the qualification I completed in preparation for my role was designed by Higher Education England in 2021. It was built around trauma-informed principles, I know no different. In addition to this, I completed my placement in a drug and alcohol service. Call me biased, (all of my professional experience comes from this specific type of agency) but I believe that community drug and alcohol services are somewhat ahead of the game of other health and care organisations in following TIP.

This isn’t necessarily because they are better versed in academic research on trauma, have better qualified practitioners or an excellent package of mandatory training. In fact, the concept of TIP has only just started being explored by ORB’s leadership at the start of 2024. We are in the early phases of collating data, brainstorming ideas, reviewing resources and developing staff training. But in my experience, we already have a strong foundation in place – an organisational culture of non-judgemental, non-stigmatising and equality-seeking attitudes towards our clients, which guide our practice and behaviours. And even though most of my colleagues may not be able to recite the six principles of TIP, or provide a textbook definition of trauma, they are excellent at being understanding, patient, compassionate, flexible and passionate about advocating on behalf of those who struggle to find their own voice.

They are able to see through the so-called challenging or anti-social behaviours and see someone who is struggling and needs help. They know how to listen without jumping to conclusions. In fact, their biggest shortcoming is probably the tendency to offer too much support to someone who may not yet be ready to receive it – because they see their struggle and really want to help, but don’t always know when and how. This important skill of recognising their own professional boundaries and knowing what to do about trauma when they see it, should probably be the focus of whatever TIP training is offered to them in the future. Because this well-intentioned behaviour comes with the risk of re-traumatising clients as well as staff burnout.

So how come drug and alcohol services already have such a strong foundation which, in my opinion, puts them ahead of the game in terms of working within the guidelines of TIP? I cannot answer this question for certain, but I do wonder whether this is partly due to the fact that recruitment of staff in drug and alcohol services seems to prioritise lived experience over academic background. Meaning, many of my colleagues have some level of personal experience of problematic substance use and what often comes with it: adversity and trauma. They’ve once been or cared for a person who struggles. They intuitively know what it feels like, what it looks like, what helps and what doesn’t. And quite often, they come to work in a drug and alcohol service not because it offers great financial gain or excellent career opportunities, but out of a strong desire to give back what was once offered to them. This level of empathy and compassion for another human being who is struggling is the critical foundation upon which any trauma-informed practices must be built.