Welcome to our Trauma Toolkit

This toolkit has been designed to help you understand the links between trauma, mental health problems, addictions and homelessness. It was developed in partnership with Exeter City Council’s Strategic Housing and Homelessness Team and is aimed at anyone working with people who struggle with addictions, mental health issues or homelessness.

Whenever we think about or focus on the traumatic life experiences of others it is important to remember that this can be upsetting and touch on our own stories and struggles. When going through this material it is important to take a break if you want to. Go for a walk, or smell a flower, whatever helps to restore you, or remind you of the other side of life.

A note about Covid-19

We started working on this toolkit back in 2019 prior to the Covid-19 Pandemic and have attempted to consider the implications of this on yourselves and your clients. We know that working practices are radically changed and are continuing to change over time. We recognise, and encourage all readers of this toolkit to also recognise, that the pandemic can be viewed through the lens of psychological trauma at an individual level, family level, community level and society.

As psychologists we encourage you to put your own, your team’s and your client’s wellbeing at the heart of everything you do.

How to use this toolkit

  • ‘Understanding Trauma’ (below) will introduce you to child development and how early life trauma can have a significant impact on a wide range of health outcomes in adulthood.

  • ‘Trauma Informed Approaches’ (via the ‘about’ menu, top right) will invite you to consider how trauma may be affecting your clients

  • The ‘Trauma Toolkit Training’ (again via the ‘about’ menu, top right) will help you to develop trauma based understandings of your clients’ difficulties and suggest ways of working with them given this. There is also guidance on your own self care and wellbeing.

Within these pages you will find information and resources to help you better understand how psychological trauma is so deeply connected to the lives of people who are or have been homeless, or present to you as at risk of homelessness.

Whilst there is plenty of science and a large and growing body of evidence on the underlying causes of trauma as well as its impacts, this has not yet been fully integrated into service delivery and direct work with vulnerable people.

Homelessness, however, is one of the few sectors that has begun, in the last five years or so, to take Trauma Informed Approaches seriously. It is visible in other sectors too but has a long way to go to be adopted in a rigorous and systematic way. Notably the Scottish health service is way ahead in this respect. Considering the evidence on how to identify and work with trauma is so compelling, it is difficult to understand the slow speed at which knowledge is translating into practice.

This Trauma Resillience Toolkit has been commissioned by Exeter City Council to compliment a range of training and Reflective Practice opportunities to support professionals, volunteers and services to make the leap into offering Trauma Informed Care, and beyond.

This work is likely to continue to develop and evolve as new evidence and practices emerge. In Exeter we want to contribute to this learning and to keep evolving our approaches to helping those clients that have experienced trauma. But also to be mindful of the impact of client trauma on our own wellbeing.

The following quote demonstrates four key considerations when adopting a trauma informed approach:

The Four Rs – An organisation that is trauma informed ‘REALISES‘ the widespread impact of trauma, stress and adversity, and understands potential paths for healing and recovery. The organisation ‘RECOGNISES‘ the signs & symptoms of trauma in staff, clients, & all others involved in the system. The organisation actively ‘RESISTS‘ re-traumatisation (trauma reducing vs trauma inducing). And, ‘RESPONDS‘ by fully & meaningfully integrating, embedding, & infusing knowledge about trauma into policies, procedures, language, culture, practice and settings. (2014)

Dr Karen Treisman – Clinical Psychologist


Understanding Trauma

What is Trauma? What are Adverse Childhood Experiences? How do they relate to Trauma and Homelessness.

Introducing Trauma

‘Trauma is widely recognised as one of the most pressing public health issues.’

Homelessness in Europe, FEANSTA 2017

The Winter 2017 FEANTSA Magazine, ‘Homelessness in Europe’, begins its comprehensive coverage of Trauma and Homelessness with the statement above, but is this true in the UK? Has this recognition of trauma as a public health issue featured highly in UK health policy? We fear this progress is slower than is needed, particularly for services designed to offer help to the most vulnerable in society, such as people who are or have been homeless.

In Exeter we are collectively acknowledging trauma and some services are organising themselves around the principles of Trauma Informed Care, perhaps because it is clear that many people are effected by childhood and adult trauma and require support not just with their housing but in recovering from a lifetime of living with traumatic experiences.

The FEANTSA publication draws upon neuroscience and developmental psychology to understand and demonstrate how trauma and its long lasting effects impact on emotions and behaviours. Importantly, the growing body of evidence has opened up new ways of working with people who ‘have often been rejected by services because of their complex needs or behaviour’ associated with their experience of trauma.

What is Trauma?

Trauma refers to harmful emotional, psychological, biological and social human responses to an event(s) or circumstances which are experienced as life threatening to the individual.

Substance Abuse and Mental Health Administration (SAMHSA) 2014

“Being traumatised means continuing to organise your life as if the trauma were still going on – unchanged and immutable – as every new encounter or event is contaminated by the past”​

Van Der Kolk, The Body Keeps the Score

Child Development, Childhood Adversity, Toxic Stress & Why They Matter

Good to know terms:

1) Adverse Childhood Experiences (ACEs)

2) Childhood Adversity

3) Toxic Stress

4) Buffering Stress

The Importance of Early Child Development

Our earliest experiences impact on the way our brains develop. These developmental experiences go as far back as pre-birth and are also affected by maternal health.

Optimal brain development requires good nutrition, freedom from chronic stress, physical and emotional security.

This video created by the Harvard Centre for the Developing Child shows (in 2 mins) how experiences build the neural architecture of the brain:

You may have heard the maxim:

‘Neurons that fire together, wire together.’

Donald Hebb

Donal Hebb, who first put forward this theory in the 1940s was referring to brain development in our early years. However, we now know that the brain remains plastic throughout life, going through a second major stage of development during adolescence, with ongoing building of our brain architecture as we repeat feelings, thoughts and behaviours.

Good human connections create good neural connections. Children need to be in an attachment relationship with at least one reliably available, protective, psychologically present and non stressed adult​.

This NSPCC ‘Brain Builders’ video explains how experiences in the first years of our lives affect how our brains form. Science tells us that the stress of abuse or neglect can damage the basic structures of a child’s developing brain. Without the right help, it can put them at risk of a lifetime of health:

What are Adverse Childhood Experiences?

Adverse Childhood Experiences (ACEs) are stressful or traumatic experiences that can have a huge impact on children and young people throughout their lives.

The ten widely recognised ACEs, as identified in a US study from the 1990s, are:

  • physical abuse

  • sexual abuse

  • verbal abuse

  • physical and emotional neglect

Growing up in a household where:

  • there are adults with alcohol and drug use problems

  • there are adults with mental health problems

  • there is domestic violence

  • there are adults who have spent time in prison

  • parents have separated

Childhood Adversity

As well as these 10 ACEs there are a range of other types of childhood adversity that can have similar negative long term effects. These include bereavement, bullying, poverty and community adversities such as living in a deprived area, neighbourhood violence etc.

Why ACEs matter

Childhood adversity can create harmful levels of stress which impact healthy brain development. This can result in long-term effects on learning, behaviour and health.

Evidence from ACE surveys in the US (see below), UK and elsewhere demonstrates that ACEs can exert a significant influence throughout people’s life.

ACEs have been found to be associated with a range of poorer health and social outcomes in adulthood and that these risks increase as the number of ACEs increase. Some of the associated increases in risk are startlingly high.

Recent research from Wales found that people who reported experiencing four or more ACES are:

Correlations Between ACEs & Mental Health Diagnoses

Likelihood of Diagnosis – for children who were sexually abused

Depression: 5.07 times more likely

Phobia: 12.12 times more likely

OCD: 7.01 times more likely

PTSD: 8.23 times more likely

Eating Disorder: 6.53 times more likely

Psychosis: 10.14 times more likely

Sources: 1. jonas, s et al. (2011) sexual abuse and psychiatric disorder in England: results from the 2007 adult psychiatry morbidity survey, psychological medicine; 41: 709-20.
2. bebbington et al (2011) childhood sexual abuse and psychosis: data from cross sectional national psychiatric survey in England, the British Journal of Psychiatry; 199, 29-37

So we can see just how much more likely an adult is to experience a mental health diagnosis as a result of childhood sexual abuse. We say more about this in the Toolkit section in a presentation called ‘Understanding Trauma’. In the ‘Working with Trauma’ presentation we point to ways in which you can work with these issues with your clients to help them understand, tolerate and change some of the distress and difficulties they are facing.

Personality No Maltreatment Childhood maltreatment

Aniti-social 3.5% 19.9%

Borderline/EUPD 3.1% 21.1%

Narcissistic 5.0% 20.3%

Histrionic 1.0% 42.4%

Source: turner et al (2017) the relationship between childhood sexual abuse and mental health outcomes among males: results from a nationally representative United States sample, Child Abuse & Neglect 66: 64-72


Taken together we can clearly see that these studies demonstrate a startlingly strong connection between childhood trauma and the development of mental health difficulties as an adult.

trauma-toxic-stress.png

The Long Term Effects of Childhood Adversity – Landmark Childhood Experiences Study

In 1998 landmark research was published called the ‘Adverse Childhood Experiences Study’ by Dr Vince Felitti (of Kaiser Permanente) and Dr Robert Anda at the American Centers for Disease Control & Prevention) were able to ask 17,421 adult Americans about current health risk factors, like smoking, drug abuse and exposure to sexually transmitted diseases as well as ‘adverse childhood experience such as child abuse, neglect and exposure to household dysfunction. 

Their goal was to determine each person’s level of exposure to ACEs by asking if he or she had experienced any of ten categories before the age of eighteen:

1) Emotional abuse (recurrent)

2) Physical abuse (recurrent)

3) Sexual abuse (contact)

4) Physical neglect

5) Emotional neglect

6) Substance abuse in the household (e.g. living with an alcoholic or a person with a substance abuse problem)

7) Mental illness in the household (e.g. living with someone who suffered from depression or mental illness or who had attempted suicide)

8) Mother treated violently

9) Divorce or parental separation 

10) Criminal behaviour in household (e.g. household member going to prison)

Each category of abuse, neglect or dysfunction counted as one point, therefore the highest ACE score was ten.

What the Study Found

  • 67% of population had a least one ACE

  • 12.6% had four of more ACEs – that’s one in every eight people

  • 87% of people who reported an ACE reported more than one i.e. there is an interrelationship between ACEs

  • there is a ‘dose / response relationship’ between ACE scores and health outcomes i.e. the higher your ACE score, the worse your health outcomes

So, for a person with an ACE score of four or more, their relative risk for a number of health problems was higher than that of a person with no ACE score. In concrete terms, they found that the risk for:

  • Two or more weeks of depressed mood in the past year – x 4.6 greater odds

  • Ever using illicit drugs – x 4.7 greater odds

  • Ever injecting drugs – x 10.3 greater odds

  • Ever attempting suicide – x 12.2 greater odds

  • Severe obesity – x 1.6 greater odds

  • Diabetes – x 1.6 greater odds

  • Any cancer – x 1.9 greater odds

  • Heart disease – x 2.2 greater odds

  • Current smoking – x 2.2 greater odds

  • Stroke – x 2.4 greater odds

  • Ever having a sexually transmitted disease – x 2.5 greater odds

  • Chronic bronchitis or emphysema (COPD) – x 3.9 greater odds

The full title of the Feletti / Anda Childhood Experiences Study: “Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults: The Adverse Childhood Experiences (ACE) study” American Journal of Preventative Medicine 14, no4 (1998): 245-58

Childhood Adversity, Toxic Stress & Building Resilience

 

Toxic Stress – And What to Do About It – Buffering the Effects

The infographic below illustrates how ACEs can impact our stress levels and the wear and tear this creates on the body and brain. Interestingly there are ways to buffer the impact of toxic stress through positive relationships and good self care. Also a range of therapuetic approaches are considered helpful in reducing toxic stress and its impacts.

acesinfographic_080218.png

Adult Trauma

Traumatic experiences are also prevalent in adulthood.

Traumatic Memories

Shane Meadows interview with the Guardian

This article in The Guardian about Film Director, Shane Meadows, is a great illustration of how tricky traumatic memories can be. By seeking help from a psychologist, who realised Shane was struggling with PTSD, he was able to access a therapy called EMDR* which helped him to recover details of a traumatic event that he had deliberately tried to forget as a young boy. Therapy provided him with the chance to recover from his symptoms whilst integrating the memories.

In some cases however, memories are sometimes brought back into consciousness by a (sometimes unrelated) but triggering or traumatising event.

“If you don’t say anything, it never happened, if you just don’t tell anyone, it never happened.”

Shane Meadows, Guardian article

“I think about that,” he says. “I was so affected and [the abuse] only happened once. I’ve had at least three breakdowns as a result; it’s caused me a lifetime of anguish, so imagine what it was like there, all that brutality and you can’t escape. Someone being able to come into your room whenever they liked…”

Shane Meadows, Guardian article

What is EMDR?

*Eye Movement Desensitisation and Reprocessing (EMDR) is an evidence based trauma focussed therapy designed to help people recover from traumatic events in their lives. It is particularly focussed on relieving flashbacks and other PTSD symptoms.

EMDR is recognised by the World Health Organisations (WHO) and the National Institute for Health and Care Excellence (NICE).

www.emdrassociation.org.uk

Trauma and Homelessness

Trauma and Homelessness, or the “Trauma Loop’ 

Research has increasingly drawn attention to the over-representation of ACE amongst homeless populations. This has been demonstrated in the UK as well as elsewhere.

Existing research indicates that ACE is a common feature in the biographies of homeless people. It is clear that socioeconomic disadvantage in conjunction with trauma in early life can have a detrimental effect on psychosocial functioning and physical health. Further to this, the experience of homelessness in itself can exacerbate previous symptoms of early trauma and increase the risk of re-victimisation.

FEANTSA – Homeless in Europe Winter 2017 – Trauma and Homelessness pp 4-6

In a study undertaken by Suzanne Fitzpatrick and Glen Bramley of Herriott Watt University (for the Lankelly Chase Foundation), it was found that those people experiencing severe and multiple disadvantage had experienced trauma, poverty and exclusion in childhood and adulthood. Those that had been in contact with all three types of service in the study – criminal justice, substance misuse and homelessness – were likely to have experienced:

  • Violent parents

  • Parents who misused drugs and / or alcohol

  • 42% had run away from home as children

  • The trauma of insufficient food (17% reported being starved)

  • A problematic time at school (almost half were suspended)

  • Almost half had no formal qualifications

85% of those in touch with criminal justice, substance misuse and homelessness services have experienced trauma as children.​


Lankelly Chase Foundation, Mapping Multiple Disadvantages 2015

Addiction, Homelessness and Trauma

A Perspective on the Psychology of Addiction

Addiction:

‘Any behaviour that gives you temporary relief or temporary pleasure but in the long term will cause you harm.’

Dr Gabor Mate – In the Realm of Hungry Ghosts, Close Encounters with Addiction 2018

 

In his book ‘In the Realm of Hungry Ghosts, Close Encounters with Addiction’, Gabor Mate, Hungarian-Canadian physician describes striking metaphors that bring the psychology of addiction to life. These are colourful descriptions divulged by his patients living in homeless hostels in Vancouver. They reveal in a few words what might take pages and pages to describe in this toolkit:

‘It’s like a warm soft hug.’

Young woman addicted to cocaine

Gabor believes that cocaine fulfilled a basic need for the young woman to feel held and safe. He explains that warmth and touch in her life has been lacking, notably throughout her childhood, as far back as infancy.

‘Like a warm wet blanket’

Long term street homeless man addicted to heroin

For the homeless man, Gabor suggests that the last time this man felt safe and held was in the womb. Gabor believes that a hit of heroin gives him this.

Of course they are dangerous and short term fixes to fundamental human needs. They speak to the suffering experienced by his patients. Or as we have already been discussing, ACEs.

Addictive Brain Chemistry

Research presented by Gabor shows how substances promote dopamine release. Dopamine is a neurotransmitter essential for incentive and motivation. It flows when we are excited, curious and seeking something e.g. partner, food, connection with others. Below you can see how great an increase in dopamine is ​experienced as a result of the following:

  • Food seeking 50%​ increase in dopamine release

  • Sex/Alcohol/Nicotine 100%​ increase in dopamine release

  • Cocaine 300%​ in dopamine release

  • Crystal Meth 1200% in dopamine release

Gabor claims that these are not inherently addictive, it is the response to these that impact those that are lacking in brain chemicals necessary for positive wellbeing. The feeling of wellbeing these activities and substances give are in deficit in the addict’s brain, hence the ongoing seeking of good feeling continues – resulting in addiction. 

The question Gabor asks is not, why are they addicted, but what pain are they trying to escape. There is a desire to escape from themselves and their minds. 

Gabor believes that all addiction is a result of ‘dislocation’ – with self, with family, with community. Very basic human needs. 

Take a look at Gabor’s TED TALK below. He’s a very engaging and expert speaker on addiction. He relates to his own addictions which he believes are a consequence of his infancy and childhood in Hungary belonging to a Jewish family following Nazi invasion. His self confessed addictions are work and spending. Both of which he feels detracted from his family life.

Trauma Informed Training packages

We have developed a package of trauma informed training presentations that you can access for free online, if you are interested just click the button below: