Enquiring about traumatic experiences in psychosis: A comparison of case notes and self-report questionnaires

Domestic violence screening in a public mental health service: A qualitative examination of mental health clinician responses to DFV

WHAT IS KNOWN ON THE SUBJECT?: Mental health clients experience higher estimated rates of domestic violence, yet mental health services are less likely to screen for domestic violence. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This paper qualitatively explores the perspectives and experiences of mental health practitioners in inpatient and community teams in a publicly funded hospital and health service (i.e. public mental health service). Mental health practitioners described a lack of domestic violence training, as well as a lack of knowledge of domestic violence and support mechanisms for victims, when domestic violence is disclosed by clients. The paper highlights the unique difficulties and barriers experienced by clinicians in screening for domestic violence while also dealing with clients suffering a mental health crisis. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The paper sheds more light on the issue of domestic violence in mental health in terms of screening, and identifies avenues for improvement in mental health services; particularly the need for staff training and education. ABSTRACT: Introduction Domestic violence is particularly prevalent within mental health client groups, though screening for domestic violence within mental health services is often overlooked. Aim To investigate the experiences and opinions of domestic violence screening by mental health clinicians in a publicly funded hospital and health service. Methods Semi-structured interviews were conducted with twelve clinicians working in publicly funded mental health services in Queensland, Australia. Transcripts were thematically analysed. Results Four main themes emerged from the data: staff training and experience; prioritizing domestic violence screening; attitudes to domestic violence; and victim support. Participants discussed a lack of training for, or expectations of, domestic violence screening in mental health services. They also highlighted a lack of resources enabling them to appropriately respond when domestic violence was identified. Discussion Education, attitudes and resources relating to domestic violence are major factors that should be addressed for the successful screening and treatment of clients in mental health. Implications for Practice This paper informs services of the gaps in knowledge and care around domestic violence and mental health. A less medicalized approach to the treatment of mental health should be adopted, and domestic violence training introduced for all healthcare practitioners, to improve client outcomes.

Adequacy of Inquiry About, Documentation of, and Treatment of Trauma and Adversities: A Study of Mental Health Professionals in England

This study aimed to ascertain how often staff in community mental health services (CMHSs) in England ask about adverse experiences in childhood and adulthood, including abuse and neglect, how often those experiences are known about and documented by staff, and how staff respond when such experiences are known about and documented. The files of 400 people using four CMHSs in England were reviewed. Only 13% of clinical records contained documentation of any adverse experiences. One percent showed clear evidence that clients had been asked about adversities. People with psychosis diagnoses were less likely to have adverse experiences documented in their file. Rates of responses to adversities of which staff were aware were high, with 90% of records indicating some appropriate support following disclosure. Future research endeavours are recommended, including on reasons for not routinely asking and on type of training needed. Recommendations are made in relation to policy change, staff training and guidelines to improve routine enquiry about adversities. Ultimately, a move to 'trauma-informed' services, already underway in some areas, is required for all mental health services.

Trauma and psychosis: a qualitative study exploring the perspectives of people with psychosis on the influence of traumatic experiences on psychotic symptoms and quality of life

BACKGROUND

Despite experiencing high rates of trauma and trauma-related conditions, people with psychosis are seldomly asked about possible traumatic events. While there are some barriers to discussing trauma in clinical services, research has shown that disclosure is not only possible but also beneficial to both psychotic and traumatic symptoms. The current study is the first to evaluate service users' perception of the influence of trauma on the development and maintenance of their psychotic symptoms, as well as their views on how their life and mental health have been affected by traumatic events and their disclosure (or lack of).

METHODS

Eleven participants with experiences of psychosis and trauma took part in semi-structured interviews.

RESULTS

Consistently with previous literature, our participants reported high rates of interpersonal trauma, but had rarely had the opportunity to discuss any of these events. Using thematic analysis, we identified three major themes that have important implications for healthcare: factors that facilitate or hinder talking about trauma; consequences of talking or not; and relationship between trauma and psychosis. Participants generally benefited from talking about trauma and concerningly often associated the prolonged lack of opportunities to discuss traumatic events with negative feelings towards the self and with a deterioration of their mental health. Participants also recognised direct links between past traumas and the content and characteristics of their psychotic experiences.

CONCLUSIONS

Our findings highlight the importance, as perceived by service users, of discussing trauma and looking at psychosis through a "trauma lens". These results stress the need to systematically assess trauma history and traumatic symptoms in psychosis and might potentially help to overcome clinicians' worries about discussing trauma with service users. Our findings underscore the need to change current practice and implement trauma-informed approaches to understand clients' difficulties and provide support.

Talking about trauma in therapy: Perspectives from young people with post-traumatic stress symptoms and first episode psychosis

AIM

Despite recommendations from national guidelines, individuals with first episode psychosis (FEP) are currently unlikely to have the effects of their traumatic experiences assessed and treated within psychosis treatment. This may be due to the mismatch between the objectives of trauma-specific treatments (directly targeting post-traumatic stress symptoms by talking about the trauma) and trauma-informed care (limiting practices that may retraumatise clients). We aimed to gain an understanding of what it was like for young people to talk about trauma in FEP treatment, and how their experiences related to the broad conceptualisations of trauma-informed and trauma-specific treatment approaches.

METHODS

Semi-structured interviews were conducted with eleven participants (18-27 years) with FEP and post-traumatic stress disorder (PTSD) symptoms after the completion of an intervention for the effects of trauma. Transcripts were analysed using an interpretative phenomenological approach.

RESULTS

Two superordinate themes were identified, each with subordinate themes. 1. Reluctance to approach the trauma memory: 1a. Not wanting to talk about trauma; 1b. Difficulty acknowledging that the trauma had occurred; 1c. Not wanting to re-experience emotions associated with trauma. 2. Factors aiding the process: 2a. Desire for change; 2b. Not being pushed to talk; 2c. Valuing the case manager; 2d. Time.

CONCLUSIONS

A majority of participants in the study experienced reluctance when recounting their trauma memories. Being in control of how trauma memories are shared and having time for the therapeutic relationship to develop enhanced participants' readiness for talking about trauma. Incorporating trauma-informed principles and motivational interviewing could aid in facilitating the processes around talking about trauma.

The association between specific types of childhood adversity and attenuated psychotic symptoms in a community sample

AIM

This study aimed to examine the relationship between types of childhood adversity and attenuated psychotic symptoms in a general population sample, and to determine the predictive role of other psychosocial factors such as resilience, coping style and social support.

METHODS

An online survey was conducted with a US-based general population sample of 748 participants (aged 18 to 35 years) using Amazon's Mechanical Turk (an online crowd-sourcing service). Participants completed the Adverse Childhood Experiences Questionnaire (ACE-Q), the Prodromal Questionnaire (PQ-16), the Brief COPE Scale, the Brief Resilience Scale (BRS), the Multidimensional Scale of Perceived Social Support and the Neighbourhood Cohesion Scale. A series of backwards stepwise hierarchical regression analyses was employed to determine the predictors of PQ-16 score.

RESULTS

Participants reported an average of 2.99 attenuated psychotic symptoms (from a total of 16), and an average of 2.77 childhood adversities (from a total of 10). In the final model, the specific types of childhood adversity which significantly predicted PQ-16 score were verbal abuse, sexual abuse and physical neglect. Resilience, as well as the coping styles of self-distraction, denial, substance use, emotional support, venting, religion and self-blame, were significant predictors; perceived social support and neighbourhood cohesion were not. This model predicted 33% of the variance in PQ-16 score.

CONCLUSIONS

The results of this study support the association between childhood adversity and attenuated psychotic symptoms in the general population. Resilience and coping styles were also important predictive factors. These data suggest potential strategies on which to focus for early intervention and prevention.

The relationship between childhood adversities and dissociation in severe mental illness: a meta-analytic review

OBJECTIVE

Several studies have observed that dissociative experiences are frequently reported by individuals with severe mental illness (SMI), especially amongst patients that report a history of adverse/traumatic life experiences. This review examined the magnitude and consistency of the relationship between childhood adversity (sexual abuse, physical abuse, emotional abuse, neglect, bullying, natural disasters and mass violence) and dissociation across three SMI diagnostic groups: schizophrenia, bipolar disorder and personality disorders.

METHOD

A database search (EMBASE, PubMed and PsycINFO) identified 30 eligible empirical studies, comprising of 2199 clinical participants. Effect sizes representing the relationship between exposure to childhood adversity and dissociation were examined and integrated using a random-effects meta-analysis.

RESULTS

The results indicated that exposure to childhood trauma was associated with heightened dissociation across SMIs. Positive significant associations were also found between specific childhood adversities and dissociation, with aggregated effect sizes in the small-to-moderate range.

CONCLUSION

These findings support calls for the routine assessment of traumatic experiences in clients with SMIs presenting with dissociative symptoms and the provision of adequate therapeutic support (e.g. trauma-focused therapies) to manage and resolve these difficulties.

Do adult mental health services identify child abuse and neglect? A systematic review

Child abuse and neglect play a causal role in many mental health problems. Knowing whether users of mental health services were abused or neglected as children could be considered essential for developing comprehensive formulations and effective treatment plans. In the present study we report the findings of a systematic review, using independent searches of three databases designed to discover how often mental health staff find out whether their clients were abused or neglected as children. Twenty-one relevant studies were identified. Most people who use mental health services are never asked about child abuse or neglect. The majority of cases of child abuse or neglect are not identified by mental health services. Only 28% of abuse or neglect cases identified by researchers are found in the clients' files: emotional abuse, 44%; physical abuse, 33%; sexual abuse, 30%; emotional neglect, 17%; and physical neglect, 10%. Between 0% and 22% of mental health service users report being asked about child abuse. Men and people diagnosed with psychotic disorders are asked less than other people. Male staff ask less often than female staff. Some improvement over time was found. Policies compelling routine enquiry, training, and trauma-informed services are required.

Are mental health staff getting better at asking about abuse and neglect?

This study ascertained the extent to which abuse and neglect are identified and recorded by mental health services. A comprehensive audit of 250 randomly selected files from four community mental health centres in Auckland, New Zealand was conducted, using similar methodology to that of a 1997 audit in the same city so as to permit comparisons. Significant increases, compared to the 1997 audit, were found in the rates of child sexual and physical abuse, and adulthood sexual assault (but not adulthood physical assault) identified in the files. Identification of physical and emotional neglect, however, was poor. Male service users were asked less often than females; and male staff enquired less often than female staff. People with a diagnosis indicative of psychosis, such as 'schizophrenia', tended to be asked less often and had significantly lower rates of abuse/neglect identified. Despite the overall improvement, mental health services are still missing significant amounts of childhood and adulthood adversities, especially neglect. All services need clear policies that all service users be asked about both abuse and neglect, whatever their gender or diagnosis, and that staff receive training that address the barriers to asking and to responding therapeutically to disclosures.