The Trauma and Self Injury (TASI) programme is systemic and multi modal in its delivery. It has been co-developed with the women who use forensic services. This population has experienced trauma, has complex post traumatic stress disorder (PTSD) related symptoms, uses self injury as a way of coping and is at risk of hurting others.
Whilst it was developed within the National High Secure Service for Women (NHSHSW) it has been integrated across a pathway of women's medium and low secure forensic services.
The programme is delivered at 3 levels; Level 1 includes proactive health and wellbeing initiatives along with co developed and delivered education; Level 2 focuses on the enhancement of a trauma informed therapeutic milieu, which promotes a safe collaborative environment enhancing the women's capacity to deal differently with their distress; Level 3 provides NICE recommended individual and group therapies. Evaluation is integral to the programme.
Aims and objectives
Aims: The Trauma and Self Injury (TASI) Programme aims via a multi-level and multi-modal approach to increase the effectiveness of the provision and approaches offered to those who are living with the impact of trauma and using self injury as a way of coping. Through systemic change the aim is to reduce the negative impact of trauma related symptoms and the incidence of self injury. Patient involvement in developing and shaping the program is pivotal. It aims to deliver a comprehensive approach at 3 levels:
Level 1 Proactive psycho education, well being & collaborative initiatives in: educating patients; enhancing coping capacity ;positive staff attitudes in promoting effective ways of minimising the impact of trauma & self injury by: Trauma & self injury self help material, Wellbeing groups, Trauma psycho-education programme, Wound care pack & training, Patient reference & development group, Staff training on Trauma & self injury co developed & delivered with patients.
Level 2 Creating a trauma informed therapeutic milieu providing a safe collaborative environment: enhancing women's capacity to deal differently with their distress;
Promoting self management & reduction of distress associated with self injury & trauma trough the use of:
Personal Distress Signatures, Safety care planning, Shared formulation of need, Ward Champions promoting positive practice on the ward, Sensory signature work linked to overcoming trauma responses, Development & use of low stim/sensory rooms
Level 3 Enhanced provision of NICE recommended therapies. To build capacity, understanding & skills to support different ways of coping with distress, through access to: Dialectical Behavioural Therapy programme Cognitive Analytical & Cognitive Behavioural Therapies Eye Movement Desensitisation Reprocessing Planning & conducting an evaluation to ensure effectiveness is integral to the programme.
Objectives are to increase:
1). Awareness & understanding of the background & meaning trauma & self injury has on people's lives. Promote engagement in activity to reduce distress & increase wellbeing.
2). Capacity for women to use effective ways of coping with distress. Enhance capacity for staff teams to make helpful & considered interventions, agreed proactively in collaboration with patients.
3). Access to meaningful & effective therapies. Promote positive change in behaviours reducing severity & frequency of PTSD symptoms & self injury.
Reasons for implementing your project
The women who use forensic services often have a complex history of trauma and are a danger to others. Their childhood histories are characterised by disruption, separations, loss of and violence by carers, neglect and abuse. Research into disrupted attachment relationships and brain development suggests that insecure and disorganised models of attachment effects capacity to manage distress and arousal. Within the forensic pathway for women high percentages of patients have experienced abuse, experience complex PTSD symptoms and the use of self injury as a method of coping.
The NICE Guidance on Self Harm (2004) identifies the link between experiences of trauma, such as child abuse and domestic violence, and self injury. Offending behaviours can be linked to a trauma response with an enactment of violence. Across the pathway over 70% of women have engaged in self injurious acts during their stay. This includes self scratching, cutting, insertion and ingestion of objects, occlusion of air ways head banging and use of ligatures.
Within forensic care, womens services experience high levels of self injurious behaviours in comparison to male services. However the use of self injury in male services is increasing. Therefore within this context it was considered that a whole systems approach to the delivery of the programme was needed.
The following are the principles/values on which it was based:
- The aftermath of trauma will leave an imprint on women in the short and long term. It will influence the way they deal with their distress.
- Each woman is a unique individual and will have their own capacity to cope with the aftermath of trauma.
- Engagement through collaboration reinforces and enhances the woman's own capacities and strengths.
- The empowerment for women to move away from a professional expert model, to a model that values women and their own experiences, was essential.
- Self injurious behaviour may have had and may continue to have a role in helping women to cope with overwhelming distress.
The challenges faced in developing a value based program arose from a culture in forensic services which focused on saftey and risk reduction. Whilst important it initially it worked against TASI. Patients were not always collaboratively involved in devising and delivering care in a meaningful way. This challenge influenced the development of the program ensuring collaboration with patients and the use of a systemic approach across the 3 levels of provision.
How did you implement the project
Methods are outlined under each level of the programme.
Staff training in understanding the imprint of trauma techniques to overcome symptoms, working with self injury in a collaborative approach; wound care; involving women patients in co-developing and co-delivering the training; Psycho Education on trauma and self injury; increased provision of self-help materials & information; co-led wellbeing group delivered in all units across the pathway; joint training for patients/staff on skin camouflage; patient reference group involved in shaping and steering the programme from a service users perspective; patient led newsletter; training for staff and patients in the use of sensory techniques to manage symptoms - particularly aroma. The programme has a Multi-disciplinary steering group.
Level 2: Women across the pathway have co-developed a Personal Distress Signature booklet which is own by them and is used in dialogue with Named Nurses/care team. This aids shared understanding of need and meaningful responses enhancing engagement and collaboration. It offers women greater influence on care provided via involvement in Care Planning. Nurse Champions promote positive practice on the ward/deliver supervision influencing positive effective interactions during times of distress. Sensory modulation techniques to help women proactively reduce arousal and dissociation are used. Low stim sensory environments under development to reduce arousal and promote wellbeing. An adapted approach to reducing harm is used to guide helpful responses.
Level 3: A multimodal integrated Trauma and self injury therapy pathway which includes an expansion of individual/group therapies (NICE recommended) in Dialectical Behaviour Therapy (DBT), CBT for trauma, Cognitive Analytic Therapy and Eye Movement Desensitisation Reprocessing (EMDR) Promotion of the TASI programme across the pathway via consultation, development work and supervision created a joined up approach for women. Presentations at local national and international conferences disseminate content and effectiveness of the approaches offered at all 3 levels of the programme. A challenge to the development and delivery of the TASI programme has been staff attitudes to self injury. With the development to a collaborative yet safe approach this has shifted over time. Time taken in rolling out training, promoting the benefits of the programme and involving patients to promote empowerment has been significant.
Effect of treatment on PTSD symptoms, self-harming behaviour & associated phenomena ie depression, anxiety & hopelessness assessed using a variety of measures including assessor rated measures, self-report instruments & records of incidents. Two formal assessment measures used in all cases: Childhood Trauma Questionnaire (CTQ; Bernstein & Fink, 1998) & Trauma Symptom Inventory (TSI; Briere, 1995). Following psychometric tools used if clinically indicated: Clinician Administered PTSD Scale (CAPS; Blake et al, 1995) Post-Traumatic Diagnostic Scale (PDS; Foa et al, 1997) PTSD Checklist (Weathers & Ford, 1996) Childhood Trauma Questionnaire (CTQ; Bernstein and Fink, 1998) Beck Anxiety Inventory (1993) Beck Hopelessness Scale (1993) Beck Scale for Suicide Ideation (1993) BDI-FastScreen (2000) HCR-20 version 3 Pre treatment scores End of therapy & follow up scores obtained + qualitative feedback.
Data collected to evaluate effectiveness of service & to influence implementation of changes to service provision. Focus groups conducted to gain qualitative feedback on impact of programme for staff & patients. Training formally evaluated as well as the information & self help packs. Key outcomes arising in the National High Secure pathway are; reduction in life threatening self injury; 43% reduction in self injury over a 2 year period in the overall population with a 73% reduction in cohort of 18 women who have accessed all levels of the programme. This cohort also demonstrated marked decrease in frequency & intensity of trauma related symptoms.
Evaluation of the training delivered with women patients was very positive with impact on practice & ward milieu; Research evaluation into use of Distress Signatures has shown positive impacts: collaborative practice between patient & Named Nurse; empowerment, hope & sense of control over influencing individualised approaches in relation to safety and proactively managing distress.3 psychometric tools used are: 1 Coping Styles questionnaire (CSQ,Roger,Jarvis, Najarian 1993) 2 Recovery-Promoting Relationship Scale (RPRS Russinova, Rodgers, Ellison 2006) 3 Scale To Access Therapeutic Relationships (STAR McGuire-Sniecknus et al, 2007) Each of the therapy programmes have their own outcome measures & note patient progression. Progress is monitored via the Forensic NICE Monitoring Group & reports are submitted & included in the Annual Report. The complexity of a multimodal program has been challenging to evaluate
Key learning points
- Key Learning Points and Barriers to implementation include:
- To overcome a risk adverse culture, limited awareness re. impact of complex trauma, differing attitudes to self injury and learning with the patient, balancing a proactive approach with the risk of hurting others; engaging a traditionally difficult to engage population the programme has championed direct links through local change agents on each ward. It has empowered and involved patients as experts in their own experiences
- Using the Distress Signatures as a collaborative tool to engage with the women has evaluated extremely well and promoted by the women who use them.
- Involving the women patients early in the reference and development group has been very helpful to ensure we co develop the programme to include their perspective into the delivery and evaluation of the programme.
- Using a systemic approach to socially engineer a change in the culture as well as to impact on provision has been essential.
- Using a multi modal three layered approach has really helped. Having the three levels of input i.e. proactive, direct care and provision of effective therapies has offered women the experience of a whole trauma informed environment.
The learning has been transferred and has impacted on the delivery and engagement of women and male patients in other forensic services. It has been particularly embraced in low and medium secure services within our trust. The learning has been widely disseminated and progress shared with members of the organisation and wider stakeholders as all progress reports via the Forensic NICE Annual Report (attached as supporting evidence.) Its impact has been shared at international, national and local conferences. An across Womens Forensic services pathway forum has also been established to share best practice.