Trauma in the lives of parents experiencing severe perinatal mental illness.

Background: The perinatal period is a time of 'high risk' for new and recurrent episodes of mental illness with 0.1-0.2% of birthing parents requiring admission to specialist mental health units in the months after birth. The prevalence and role of trauma in the lives of birthing parents (most commonly mothers) experiencing severe perinatal mental illness is not well known. Method: In a new perinatal mental health unit in Sydney Australia, a retrospective audit of trauma prevalence was undertaken using patient completed questionnaires and electronic medical record data. Descriptive analysis was undertaken. Results: Prevalence of trauma in the lives of mothers with severe mental illness was found to be higher than that reported in general or community mental health settings, with 76% of mothers reporting lifetime trauma exposure and 24% meeting criteria for complex PTSD. The majority reported trauma experiences likely to impact attachment and also reported difficulties in responding to their infants' cues and needs. Discussion: The findings suggest a need for more research, awareness, and consideration of the role of trauma in experiences of perinatal mental illness, with implications for developing trauma informed models for responding to parental mental illness.

Birth trauma in a population requiring inpatient mental health care in the postpartum period.

OBJECTIVE: This study explores rates of birth-related symptoms of trauma in a population of parents experiencing severe perinatal mental illness. METHOD: Birthing-parents admitted to a perinatal inpatient unit completed birth trauma measures on admission which were descriptively analyzed. RESULTS: The population had higher rates of birth-related potentially traumatic events and trauma-related symptoms than the general population. CONCLUSIONS: The findings highlight that assessing for and responding to experiences of birth trauma is highly relevant to an inpatient perinatal population.

An audit and analysis of electro convulsive therapy patient information sheets used in local health districts in New South Wales Australia.

Electroconvulsive Therapy (ECT) is a widely used psychiatric treatment; however, it remains contentious. It is therefore important that people are provided with accurate and balanced information before consenting to ECT. The aim of this study was to audit and analyse the content and language of ECT information sheets used in local health districts (LHDs) across the state of New South Wales Australia. Descriptive content analysis and evaluative linguistic analysis were used to investigate the information sheets, with findings then considered from a mad studies perspective. Thirteen ECT information sheets were obtained and reviewed, with the audit finding they lacked accuracy and balance. Linguistic tools were used to exaggerate positive outcomes and minimise negative effects. Despite commonalities, the structure and content of the sheets varied considerably. Findings indicate a need for co-design and co-production approaches to developing ECT information sheets. This should occur in genuine partnership with lived experience representatives based on current evidence, using neutral language, and with attention to their intent as part of processes of informed consent and decision making.

Trauma and the perinatal period: A review of the theory and practice of trauma-sensitive interactions for nurses and midwives.

AIM: With high rates of trauma in the population, known links between trauma and perinatal distress, and the intimate and close nature of the nursing and midwifery roles, ensuring awareness and understandings of trauma is crucial for guiding practice. This paper aims to explore the relationship of trauma to the perinatal period, based on theory and practice, to consider on how nurses and midwives can deliver trauma-sensitive interactions. DESIGN AND METHODS: This discursive discussion draws on relevant research from the fields of trauma therapy, attachment theory and nursing and midwifery practice to consider elements of trauma-sensitive practice in the perinatal period. RESULTS: Nurses and midwives can foster safety for people who have experienced trauma through noticing and responding to triggers, supporting awareness of attachment and its relationships to trauma, undertaking psychosocial screening with care, supporting linearity and cohesion in narratives and developing collaborative care plans that maximise safety and agency. For nurses and midwives, understandings of the relationship between trauma, pregnancy, birth, early parenting and distress is crucial for effective care delivery. Delivering perinatal nursing or midwifery care of any kind, without universal trauma precautions risks reinforcing, misinterpreting or re-enacting dynamics of trauma. To be trauma-sensitive in this period requires nurses and midwives to have awareness of the dynamics of trauma in relation to pregnancy, birth and attachment. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: This paper fills a gap in the translation of theory to practice for trauma-sensitive care in the perinatal period, with a focus on the therapeutic relationship formed by nurses and midwives. The findings highlight that nurses and midwives can foster safety for people who have experienced trauma within their practice, when they hold a robust understanding of the relationship between trauma, pregnancy, birth, early parenting and distress. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

Editorial Perspective: Prato Research Collaborative for change in parent and child mental health - principles and recommendations for working with children and parents living with parental mental illness.

Children whose parents have mental illnesses are among the most vulnerable in our communities. There is however, much that can be done to prevent or mitigate the impact of a parent's illness on children. Notwithstanding the availability of several evidence-based interventions, efforts to support these children have been limited by a lack of adequate support structures. Major service reorientation is required to better meet the needs of these children and their families. This editorial provides recommendations for practice, organisational, and systems change.

Bridging the gap: A new integrated early intervention service for young people with complex mental health issues.

AIM: Two integrated headspace Early Intervention Teams (hEITs) were established in 2017 to bridge gaps between headspace, the national primary care youth mental health programme in Australia, and the state funded secondary and tertiary mental health services. This study aims to describe functioning and outcomes of patients referred to hEIT over a 6-month period. METHODS: A retrospective file audit was conducted for all patients accepted into the service over a 6-month period in 2018. Measures of distress, functioning and client satisfaction were collected and analysed. Exemplar vignettes were created to construct hypothetical examples and illustrate research findings. RESULTS: At admission, the three most common presentations were depression/anxiety, trauma and stress related, and psychotic disorders. During their time in the service, young people displayed a statistically significant improvement in functioning, reduction in self-harm in those 18 years and under, and a trend to reduction in distress scores. hEIT delivered a broad range of services covering social, occupational, educational, medical and mental health care, and the service was experienced positively by the patient cohort. CONCLUSIONS: hEIT appears to meet the needs of young people requiring greater care than primary care services can deliver. The integrated, wrap-around care coordination facilitates treatments across social, educational and health domains. Further exploration of young people who disengage from care, improved outcome data reporting and economic evaluation are indicated.

Vicarious trauma and nursing: An integrative review.

Nursing requires empathic engagement, within therapeutic relationships, to ensure the delivery of compassionate care. Empathic engagement with people who have experienced trauma is known to potentially lead to experiences of vicarious trauma occurring in the caregiver. However, relatively little is known about the implications of vicarious trauma for nurses. This integrative review aimed to explore what is known about vicarious trauma and consider its implications for nursing. Twenty-two articles were included in the review, with findings considering how vicarious trauma is conceptualized and applied to nursing in the literature, what implications of vicarious trauma, specific to nursing, are identified in the literature, and what vicarious trauma interventions are identified to apply to nursing. The findings highlight clear articulation of the concept of vicarious trauma and its relevance to nursing, including its pervasive and significant personal and professional effects. Vicarious trauma was identified to be a workplace hazard for nurses working across settings, which also impacts upon organizations. The review highlighted that at individual, team, organizational, and social levels, awareness and preventative approaches are recommended. These approaches require systemic supports that foster individual coping mechanisms, self-care and support networks for nurses, education about vicarious trauma, screening for vicarious trauma, and formalized access to clinical supervision and peer support for all nurses. With increasing awareness of trauma across health care settings, and a move towards the delivery of 'trauma informed care', recognition of vicarious trauma amongst nurses as a likely 'cost' of the delivery of compassionate care to trauma survivors, is essential.

Towards epistemic justice doing: Examining the experiences and shifts in knowledge of lived experience researchers over the course of a mental health research training programme.

Participation of people with lived experience (LE) in mental health research is vital for improving the quality and relevance of research priorities, outcomes, and knowledge translation. Inclusion of people with LE is also recognized as central for achieving health service reform including commitments to human rights, social, and epistemic justice. Although a lack of research training is cited as a barrier to LE participation, few studies have examined the value of training for, or the specific requirements of, people with LE. This study seeks to address this gap. It reports on a longitudinal, qualitative study examining shifts in experience and knowledge, and unmet needs, of people with LE over the course of a coproduced research training programme. Findings indicate that the programme enabled participants to understand the role, value, and levels of LE participation in research. Participants also stressed the importance of the 'embodied lived expertise' of LE researchers who co-delivered the training programme. Nonetheless, participants indicated that they felt unprepared for the challenges of working in systems where LE knowledge is subordinated, and experiences of being silenced and powerless could mirror those previously experienced in mental health services and the community. Participants indicated a need for training that provided them with the epistemic resources to render such experiences intelligible. Findings also indicate that training in participatory research is required for conventional mental health researchers, to support them to navigate power asymmetries and value LE knowledge contributions.

Is trauma informed care possible in the current public mental health system?

OBJECTIVES: As mental health services move towards implementing 'Trauma-informed care', there is a need to consider the challenges posed within services and systems. This paper raises some of the challenges associated with integrating TIC into the current public mental health system. . CONCLUSION: The lack of clarity about expectations of trauma-informed approaches causes difficulties for its integration into services, but the wider political context of mental health services is also of relevance. Transparent and ongoing debate is required about approaches to mental health care, to ensure the system meets the needs of those who require it, while questioning what other purposes it may be serving at social and political levels.

Trauma-informed qualitative research: Some methodological and practical considerations.

Mental health nurses who engage in research are likely to undertake research on sensitive topics, related to experiences of illness, care delivery and treatment. With recognition of the high prevalence of trauma in the lives of people who interact with mental health services, it is likely that many research participants will have experienced trauma in their lives and that while this may not be the focus of the research, sensitivity and awareness are required. Reference to 'trauma-informed' approaches in research design and practice is emerging in fields such as trauma-focused research and social sciences; however, it has not yet been applied to nurses. Trauma-informed approaches can build upon existing ethical and methodological frameworks to inform how mental health nurses go about qualitative research and what they need to consider when doing so. This discursive paper explores some of the implications of awareness and sensitivity to trauma for research undertaken by mental health nurses, including practical and methodological considerations. Recommendations include training and structural supports for nurse researchers, collaborative research designs, consideration of the environments where research occurs, awareness of approaches to distress and inclusion of trauma sensitivity within research policies, frameworks and leadership, alongside vigilance to interpersonal approach and the establishment and protection of psychological safety throughout. Continuing to undertake research on topics, and with people, where trauma is present, is essential to ensure ongoing awareness. Many of the existing skills held by mental health nurses can also support research to be undertaken in trauma-informed ways.

The 'trauma' of trauma-informed care.

OBJECTIVES: As mental health services increasingly position themselves as providing 'trauma-informed care', there is a need for ongoing critical reflection on the challenges that this movement highlights for mental health services, including those related to the concept of trauma itself. CONCLUSIONS: To become trauma-informed requires opportunities to reflect on what trauma means and consideration of the challenges the concept poses to diagnostically driven systems. Alongside uptake, further debate is required.

Clinician stakeholder experiences of a new youth mental health model in Australia: A qualitative study.

AIM: Late teens and early adulthood is the peak age of onset for mental disorders. Currently, there is a gap between primary mental health care and more intensive mental health services for young people in New South Wales (NSW), Australia. Two headspace Early Intervention Teams (hEITs) were developed to bridge this gap in Sydney Local Health District (SLHD), in Sydney, Australia. This study aims to explore clinician experiences of hEIT after the first 2 years of implementation. METHODS: Semistructured interviews were conducted with key clinicians working within hEIT or closely associated with hEIT. Nine interviews were conducted, transcribed and analysed using qualitative thematic analysis. RESULTS: Four themes were identified: (1) building a bridge between services, (2) filling a clinical gap, (3) service collaborations and their challenges and (4) difficulties of small team size. CONCLUSIONS: There is evidence that clinicians value the service provided by hEIT. There are difficulties such as referral confusion, staff turnover and suggestions to increase staffing to improve the stability, skill diversity and viability of the service. Findings have implications for other collaborative youth mental health models.

A qualitative inquiry into psychiatrists' perspectives on the relationship of psychological trauma to mental illness and treatment: implications for trauma-informed care.

BACKGROUND: Trauma is a factor impacting the lives of many people experiencing psychiatric disorders. Trauma affects people's responses to illness as well as their interactions with services. AIM: This study aimed to explore the understandings and experiences of psychiatrists of working with trauma and emerging models of Trauma-Informed Care. METHODS: An interpretive qualitative inquiry was undertaken using semi-structured in-depth interviews with psychiatrists. RESULTS: Four themes were identified: Making sense of trauma; A contentious relationship between trauma and mental illness; Treatment made more challenging by trauma; Trauma-Informed Care highlights tensions. Psychiatrists are familiar with the concept of trauma but there are differences in beliefs about its relationship to mental illness that are consequential for practice. Trauma-Informed Care is seen as an effort to humanise mental health services, but with perceived limited impact on psychiatrists' roles. CONCLUSION: Findings indicate need for further consultation and collaboration with psychiatrists around trauma-informed care implementation; as well as consideration of what is required to develop professional consensus on trauma and its relationship to illness.

Intergenerational Trauma and Its Relationship to Mental Health Care: A Qualitative Inquiry.

Intergenerational trauma is a discrete form of trauma which occurs when traumatic effects are passed across generations without exposure to the original event. This qualitative study aimed to explore how psychiatrists understand intergenerational trauma in respect to their practice, for the purposes of identifying interventions for addressing intergenerational trauma in public mental health services. Findings revealed that psychiatrists observe intergenerational trauma frequently in their roles and try to opportunistically promote awareness of trauma with adults, and refer families to external services for supportive interventions. They feel powerless when faced with directly intervening with intergenerational trauma and required restructuring of their roles to adequately address it in public settings. Findings have implications for training, advocacy and research on the relationship between trauma and mental illness. Alongside this, there is an indicated need for examination of how systems can ensure access to appropriate services once organisations become trauma-informed.

Does a community based recovery service reduce inpatient bed days?

OBJECTIVE: Increasing options for the delivery of community-based care may be one way to reduce inpatient bed pressures. This study set out to examine the effect of community-based step up/step down (SUSD) care on hospital usage for service users with multi-service usage. METHODS: A retrospective audit was undertaken of the medical records of all individuals admitted to a SUSD unit over a 2-year period, calculating inpatient bed days for the 12 months prior to, and the 12 months after, the SUSD admission. RESULTS: There was a statistically nonsignificant decrease in bed days in the 12 months following admission. CONCLUSION: It is possible that inpatient bed day reduction may not be an appropriate outcome measure for a service built on principles of personal recovery. How to translate recovery-outcomes to justifiable financial benefits for services requires further consideration and alignment of values with reporting measures.

Involving Mental Health Consumers in Nursing Handover: A Qualitative Study of Consumer Perspectives.

A number of benefits have been identified for including consumers in nursing handover, such as improved safety and information exchange. In mental health settings these benefits may translate to improved nurse-consumer engagement and working towards the provision of recovery orientated practice. The process of including the consumer, whilst considered best practice, is not well established in mental health settings. Therefore further understanding, in regards to the consumer perspectives about this practice, is needed to inform its adoption and implementation.This qualitative descriptive study explores consumers' perspectives of their possible involvement in the nursing handover process within a mental health inpatient setting. The study took place in two mental health inpatient units in regional New South Wales, Australia. Thirteen semi-structured individual interviews were conducted with consumers, and a conventional content analysis method was used to analyse the data. Findings are presented under two categories: understanding the purpose and process of nursing handover and considering consumer involvement in handover.Findings provide insight into the views of consumers about being involved in nursing handover and further strengthen the rationale for establishing the process as part of routine practice within acute inpatient mental health units. The study also highlights the need to ensure that all processes within these settings accommodate consumer perspectives and involvement.

'What would a trauma-informed mental health service look like?' Perspectives of people who access services.

Trauma-informed care is an approach to the delivery of mental health care based on an awareness of the high prevalence of trauma in the lives of people accessing mental health services, the effects of trauma experiences and the potential for trauma or re-traumatization to occur in the context of care. Across Australia, inquiries and reports have increasingly indicated an urgent need for mental health services to become trauma-informed. However, how Australian mental health services should deliver trauma-informed care is not well documented. Efforts towards trauma-informed care in any setting require engagement with those who receive care. This qualitative study used an experience-based co-design methodology to explore the perspectives of consumers of mental health services in Australia and their family members, in relation to the question 'what would a trauma-informed mental health service look like?' Focus groups were held with consumers (n = 10) and carers (n = 10). Thematic analysis of transcripts identified that consumers and carers consider that trauma-informed care requires increased awareness of trauma amongst mental health staff, opportunities to collaborate in care, active efforts by services to build trust and create safety, the provision of a diversity of models and consistency and continuation of care. The findings provide important new information about the experiences of Australian service users and have implications for the implementation of trauma-informed care across settings.

What is needed for Trauma Informed Mental Health Services in Australia? Perspectives of clinicians and managers.

Trauma Informed Care is an approach to the delivery of mental health care that requires sensitivity to the prevalence and effects of trauma in the lives of people accessing services. While TIC is increasingly emphasized in mental health policy and frameworks in Australia, people working in mental health settings have reportedly struggled to translate the values and principles into their everyday practice. This qualitative study used an experience-based co-design methodology to explore the potential for implementation of Trauma Informed Care into mental health services in Australia. The experiences of consumers, carers, clinicians, and managers were gathered. This paper presents the perspectives of clinicians (n = 64) and senior managers (n = 9) from across three Local Health Districts in New South Wales in Australia. All data were analysed thematically to address the research question: What is needed for Trauma Informed Mental Health Services in Australia? To be trauma-informed, managers required: leadership at all levels, access to resource, relevant and accessible training, support for staff, resolution of wider systems issues, and clarification of the concept and actions of TIC. Clinicians identified that to be trauma-informed they required services to: be aware of staff well-being, support different ways of working, address workplace cultures and provide increased resources. The findings have implications for any service, team or individual seeking to implement TIC within mental health settings.

A frog in boiling water? A qualitative analysis of psychiatrists' use of metaphor in relation to psychological trauma.

OBJECTIVE: Tensions about the definition, diagnostics, and role of psychological trauma in psychiatry are long-standing. This study sought to explore what metaphor patterns in qualitative interviews may reveal about the beliefs of psychiatrists in relation to trauma. METHOD: A qualitative inquiry using systematic metaphor analysis of 13 in-depth interviews with Australian psychiatrists. RESULTS: Three themes were identified: a power struggle between people, trauma, and psychiatry; trauma is not a medical condition; and serving the profession to protect society. CONCLUSIONS: Metaphors present trauma as a powerful force that people can manage in different ways. Psychiatrists may view trauma as a social rather than medical issue. Psychiatrists experience role pressure associated with trauma including incongruence with risk management expectations of their roles.

Involving mental health consumers in nursing handover: A qualitative study of nursing views of the practice and its implementation.

Nursing handover occurs between shifts and is an important means of communication and information exchange around consumer care. The involvement of consumers in nursing handover, known as 'bedside handover', is well established within general health settings and promotes a patient-centred approach to care. Bedside handover represents an opportunity for mental health settings to consolidate recovery-oriented principles, albeit with some unique challenges in the way that involving consumers in nursing handover is implemented. This qualitative descriptive study explores the views of nursing staff and nursing managers about involving consumers in nursing handover and the process of implementation across five mental health inpatient units in Australia. The study took place in a local health district covering regional and rural areas of New South Wales that had issued a directive to implement bedside handover. The consolidated criteria for reporting qualitative research (COREQ) checklist was applied to this study. Six focus groups were held with nursing staff (n = 22), and eleven individual interviews were undertaken with nursing managers to explore their perceptions of bedside handover and its implications for nursing practice. The data were analysed using thematic analysis. Data from focus groups and interviews were analysed separately and then combined to generate three themes: (i) the mental health context is different; (ii) protecting consumer privacy and confidentiality; and (iii) it might make things worse. The findings provide insights into both the challenges, and the process of involving consumers in nursing handover within mental health settings and provides guidance for future implementation.