2. Have an Awareness of the Impact of Trauma (Part 2)

Introduction

This is the second part of a two-part article about having an awareness of trauma. You can find the first part here which is an overview of some of my learning about trauma and its impact. And in this second part of the article I am going share my thoughts on how having an awareness of the impact of trauma might assist when you are working with conflict.

I think it important at the start to share my view that having an awareness of trauma differs from ‘diagnosing’. And that it is not about being a therapist. For me, having an awareness of trauma is about a shift in your thinking. It is about recognising the impact that trauma can have and being able to work with conflict in a way that does not cause trauma, prevents replication of any prior trauma dynamics and so diminishes the likelihood of re-traumatisation.

The ’Window of Tolerance’

When working with conflict I have found ‘The Window of Tolerance’ concept to be helpful. I understand that the Window of Tolerance was described originally by Dr Dan Siegel as the optimal zone of arousal within which a person is typically able to readily receive, process and integrate information and otherwise respond effectively to the demands of everyday life.

And I have learned that trauma can narrow the window of tolerance, with triggers related to trauma increasing emotional responses and leading to states of either hyper or hypo-arousal, which are states in which a person is not able to function as effectively. Hyper-arousal is also known as the “fight, flight or freeze response” and is a heightened state of activation/energy – so reactions to potential threats are neither proportionate nor predictable. Hypo-arousal - which is also known as the ‘shutdown’ or ‘flop’ response - can result in a person going numb, detaching or disassociating from a situation.

Someone who has experienced trauma can be highly alert to situations in the present that have something in common with past traumas. And people who have experienced trauma often have challenges with regulating their emotions, so the zone of arousal in which they can function effectively can become quite narrow. I have read that people impacted by trauma can move rapidly between hyper-arousal and hypo-arousal states. And if you want to learn more there is a helpful NHS Education for Scotland video on ‘The impact of psychological trauma on our window of tolerance.’

Trauma Informed Principles and Practice

So – what can we do to best enable a person to be present in the ‘window of tolerance’ when we are working with conflict? I think a significant answer to this lies in being trauma aware. In what has been described as ground-breaking work, Harris and Fallot (2001) recognised that many people who were in contact with ‘human services’ had experienced trauma and in response to this have written that being informed about trauma can mean two specific - yet very different - things. Firstly, to be trauma informed means “to know the history of past and current abuse in the life of the consumer with whom one is working”. But secondly, “to be trauma informed means to understand the role that violence and victimization play in the lives of most consumers of mental health and substance abuse services and to use that understanding to design service systems that accommodate the vulnerabilities of trauma survivors and allow services to be delivered in a way that will facilitate consumer participation in treatment.”

Harris and Fallot (2001) wrote that the commitment of trauma informed services is “to provide services in a manner that is welcoming and appropriate to the special needs of trauma survivors.” And my understanding is that the key principles that underly the development of trauma informed practice have - in the main - followed on from their work. As set out in the SAMSHA publication Concept of Trauma and Guidance for a Trauma-Informed Approach (Huang et al 2014), and while there may be variations, these principles are generally agreed to include safety, trustworthiness, collaboration, empowerment and choice - along with the need for peer support and recognition of cultural, historical and gender issues.

Writing about trauma informed mental health services, Sweeney et al (2018) say that “The fundamental shift in trauma-informed approaches is moving from thinking ‘What is wrong with you?’ to considering ‘What happened to you?”. In essence a paradigm shift. And that “Rather than being a specific service or set of rules, trauma-informed approaches are a process of organisational change aiming to create environments and relationships that promote recovery and prevent re-traumatisation.” So in a trauma-informed service, it is assumed that people have experienced trauma and may consequently find it difficult to develop trusting relationships with providers and to feel safe within services.

 Trauma Aware Resources

Related to this, I wrote in my 2020 article ‘Being Trauma Aware’ about the Government in Scotland commitment to developing an adversity and trauma-informed workforce. The resulting National Trauma Training Programme led by NHS Education for Scotland (NES) is based on the five trauma principles and informed by people with lived experience. This Programme considers that trauma-informed practice and policy is as relevant to staff as it is to people accessing services. And it is vital for staff have access to relevant training, supervision and support that helps them to understand the potential impact of trauma and vicarious trauma on both them and the citizens they work with. This work has resulted in informative free resources – see here.

And it is worth mentioning that The Improvement Service’ in Scotland has developed a series of companion documents to strengthen awareness and understanding about trauma-informed practice when working with people affected by domestic abuse, by drug/alcohol use and where people are affected by mental health difficulties. Also that Elliott et al (2005) have written about the principles underlying trauma informed services for women, which they consider reflect the values and practices that define a trauma-informed service organization. There is also excellent learning in a 2022 report by Women’s Aid - Are you listening? whose research identified seven key elements of a good mental health response for survivors of domestic abuse.

Learning related to interviewing

As a researcher, as well as a mediator and in my own complaint resolution work, I often interview people and ask questions. So it has been fascinating to read the findings of Langballe and Schultz (2017), who interviewed 320 survivors of the July 2011 massacre at Utøya, Norway to explore their experiences of the investigative police interview conducted after the event. The young people who reported the investigative interview to be a positive situation said that they: regarded the interview as meaningful, could control their own narrative (they were allowed to speak freely at their own pace), were listened to by an interviewer promoting safety, were able to cope with emotional reactions during the interview and perceived the police as empathetic and professional.

I have also read a paper by Risan et al (2020) which aims to outline recommendations for police interviewers when approaching traumatized adult witnesses. In addition to having a helpful summary about the impact of trauma, the authors describe the importance of building rapport, facilitating free recall and accommodating/managing emotions to maintain rapport. Their conclusions include that “A constructive interview holds the potential of both eliciting an optimal account and having positive effects on the well-being of the interviewee …. This does require, however, that the interviewer has an understanding of the impact of trauma and tailors each interview accordingly.”

And I have found helpful the practice recommendations about interviewing in a 2021 article by Dr Sophie Isobel on Trauma-informed qualitative research, which I suggest have relevance to trauma-informed interviewing in other contexts. Interestingly, Isobel (2021) acknowledges “the challenges related to the global pandemic necessitating that interviews are commonly being conducted via zoom or telephone instead of face to face, with findings that videoconferencing users for therapeutic purposes have reported that they are able to concentrate more on the words being said and find it easier to discuss sensitive topics.” This reflects my own experience and I endorse her view that “some people who have experienced trauma may prefer online or phone connections, and where possible, participants should be given choice.”

[As an aside – there are an increasing number of thought-provoking academic articles about interviewing in virtual environments, including one by Geller (2020) which includes tips to help therapists create an environment to cultivate and communicate presence in online sessions in order to strengthen positive therapeutic relationships and another by Dando et al (2022) who have investigated interview context and rapport-building behaviours in virtual environments].

The Isobel (2021) article isn’t ‘Open Access’, so in quick summary her helpful recommendations relating to interviewing include: giving consideration to the environment in which the interview will take place, the design of the interview schedule, interpersonal safety and power dynamics; that the critical factor when designing interview questions is not what the questions are but how they are asked; that some participants prefer to share the most emotional and pressing component of their experience first, such that they can then proceed; simple grounding techniques can bring the individual’s attention back to the present moment (such as ‘refocusing’ on the questions or offering a drink of water); to give back power by offering choices where possible including the opportunity to pause; and that at the end of a trauma informed qualitative interview it is important to allow the participant time to share unstructured thoughts.

Isobel (2021) also comments how “Many people want to please others in formal interactions such as research interviews, with the power dynamics leading people to answer questions in ways that are useful to the interviewer.” This has certainly been my own experience. And in relation to working with conflict, I have an increasing interest in both conversation analytics and the power of storytelling, which can be a means of using personal experiences to talk about issues in a broader way. And I welcome Ella Saltmarshe writing in 2018 that “We need to develop new processes of collective storytelling across sectors to navigate turbulent times and foster systems change” and setting out three qualities of story and narrative - which are story as light, as glue, and as web - that all sectors can use to change systems.

I will return to the importance of both conversation analysis and storytelling in later articles, including consideration of whether the role of a conflict resolver includes shifting focus to the future and away from storytelling about past. But to say now that there is much to learn about therapeutic conversations from colleagues who work as counsellors and therapists. And that I am taken with the resources available on the website of the Dulwich Centre in Adelaide, Australia - who use narrative approaches to therapy and community work. Their website explains that “narrative therapists think in terms of stories – dominant stories and alternative stories; dominant plots and alternative plots; events being linked together over time that have implications for past, present and future actions; stories that are powerfully shaping of lives” and they have a Narrative Therapy Charter of Story-Telling Rights.

Trusting Relationships

Central to the approaches advocated by Isobel (2021) is that the researchers’ role is to enact the trauma informed principles of safety, trustworthiness and choice, so that people with known or unknown trauma histories can feel able to either share or not share the words that are important to them. Sweeney et al (2018) have written that that “Trauma-informed practices use strengths-based approaches that are empowering and support individuals to take control of their lives and service use”.

Also that “Trusting relationships are built between staff and service users through an emphasis on openness, transparency and respect. This is essential because many trauma survivors have experienced secrecy, betrayal and/or ‘power-over’ relationships.” And they refer to earlier research findings that “Underpinning positive therapeutic alliances are the basic human qualities of staff and their ability to communicate these to service users. All service users valued relationships with staff who demonstrated kindness; warmth; empathy; honesty; trustworthiness; reassurance; friendliness; helpfulness; calmness; and humour.”

I believe that there is much that we, as individuals, can do through being both trauma aware and informed when working with conflict to develop trusting relationships so that all involved feel safe, can work collaboratively, feel empowered and have choice. And there has been recognition (see the work of NHS Education for Scotland above) that safe, collaborative, supportive and empowering workplaces are central to the success of trauma-informed approaches, as this enables workers to relate to others in a trauma-skilled way and to cope with adversity and trauma in their own lives.

 Safe Environments

My learning has been that the nature of a conflict is often shaped by the institutional and social contexts within which it occurs. And the need to create a safe environment when working with conflict will not be a new concept to many. But I suggest that a safe environment in a trauma-informed context far exceeds the standard ‘obligations’ of many organisations to do with physical safety, security and having policies and procedures related to ‘challenging behaviour’. And in relation to this terminology, I have already written about the use of language and labels in 'Seeing the Person Behind the Behaviour' and plan to say more in later articles. 

I know that Sweeney et al (2018) have written that “forms of (re)traumatisation include the use of ‘power-over’ relationships that replicate power and powerlessness by disregarding the experiences, views and preferences of the individual”. And I referred to learning from Dr Adam Burley (who is a Consultant Clinical Psychologist working in and around homelessness and health exclusion) in Part 1 of this article. To add to this, I have been fortunate to hear him speak about services often making provision for the barriers resulting from physical trauma - such as having wheelchair access to buildings - but not making equivalent access provisions for people with relational trauma whose barriers are likely to be invisible. Dr Burley has spoken about how people with relational trauma were being asked to do things that were impossible for them when accessing services, such as going into strange rooms with strangers and having the door closed behind them.

Institutional and Organisational Barriers

Sweeney et al (2018) acknowledge that many staff working in UK public services already engage in trauma-informed practices (without perhaps naming them as such) and in their paper explore the systemic barriers that can prevent individual staff from fully engaging in trauma-informed relationships. These include barriers relating to austerity, underfunding and lack of resources (particularly staff shortages), time needed for paperwork, grappling with top-down, unpredictable and frequent change, and low morale/high staff turnover. They have also identified barriers relating to a lack of supportive organisational cultures (such as being risk-averse and there being little opportunity to reflect on practice) and barriers relating to the continuing dominance of biomedical models of mental distress. And there is more on overcoming these barriers in an article by Sweeney et al (2016).

In the first part of this article I highlighted aspects of trauma in institutions and organisations. Lewis et al (2019) when writing about institutional betrayal in healthcare, say that “Common healthcare-related institutional betrayals include lack of enactment of systemic policies to prevent negative healthcare experiences, systematically failing to respond appropriately to significant health-related concerns, institutional barriers making it difficult to report a negative healthcare interaction, and maintaining or even fostering an environment in which negative healthcare experiences are more likely to occur.”

I also wrote in Part 1 about the work of Professor Jennifer Freyd. She has introduced the terms ‘Institutional Courage’ as being the antidote to institutional betrayal and has written in a 2020 The Conversation article about institutional betrayal in relation to sexual assault. Freyd says in this article that “details of institutional courage depend to some extent on the type of institution involved, but there are 10 general principles that can apply across most institutions.” And her research-based steps toward institutional courage include leadership education, conducting anonymous surveys, being accountable and open to apology, education regarding responding well to disclosures and reports, engaging in self-study, keeping data and policies transparent and rewarding truth-telling.

And revisiting the Meus White Paper - A Framework for Working with Organisational Trauma referred to in in Part 1 of this article and which considers organisational trauma to be a constellation of symptoms that is “characterised by broken connections between individuals in that organisation; between parts of the organisation; and between the organisation, its stakeholders and wider society”. This paper shares a helpful framework for diagnosing organisational trauma, with an approach based on organisations needing to have both conversational spaces and action pathways interconnected by revitalised leadership - and says that “While leaders cannot always protect an organisation from trauma, they can help protect the organisational culture from traumatisation.”

And Finally

There is so much more we can do on being trauma aware and applying our learning and I know that I am only skittering along the surface in what I write here. Sweeney et al (2018) end their article by stating their “belief that lone practitioners can take big leaps towards becoming trauma-informed, even where they face cultural and organisational barriers.” But a bit depressingly in relation to healthcare, Emsley et al (2022), in their qualitative study Trauma-informed care in the UK: where are we? conclude that “Although health policies endorse implementation of TI approaches in the UK, they do not provide specific legislation, strategy or funding and are not supported by evidence of effectiveness.” Although they did find “more centralized implementation of TI approaches in Scotland and Wales versus piecemeal implementation in England.

My hope is that people who work with conflict and have an awareness of the impact of trauma will adjust their own approach and practice - and so lead by example. Small changes can be radical and this is about us moving from knowing (as in having the information) to doing things differently. And that while changes and adjustments in individual practice are beneficial, what is really needed is a paradigm shift in organisational approach. So while I endorse the prompts and requirements to ‘make reasonable adjustments’, wouldn’t it be better to have dispute systems that work for everyone as they are inclusive of the substantive, procedural and psychological needs of all? I do appreciate that system change isn’t easy, but if willing, there is much that organisations can learn from being trauma aware and to use this awareness to design trauma-informed systems and approaches relating to both internal and external conflict.

Related to this, in a future article - in addition to this series - I plan to share the learning from research undertaken with colleagues on ‘therapeutic complaint resolution’, which draws on concepts from therapeutic jurisprudence, as I believe this has particular relevance to working well with conflict. This learning includes our view that a therapeutic approach involves putting the people at the centre of dispute system design processes in order to counter both asymmetrical and systemic power which can permeate these systems.

But for now, the next article in this Working with Conflict series will be about understanding your own response to conflict.

References

Dando, C., Taylor, D.A., Caso, A., Nahouli, Z. and Adam, C., 2022. Interviewing in virtual environments: Towards understanding the impact of rapport-building behaviours and retrieval context on eyewitness memory. Memory & Cognition, pp.1-18.

Elliott, D. E., Bjelajac, P., Fallot, R. D., Markoff, L. S., and Reed B. G. 2005. Trauma-informed or trauma-denied? Principles and implementation of trauma-informed services for women. Journal of Community Psychology, 33, 461-477.

Emsley, E., Smith, J., Martin, D. and Lewis, N.V., 2022. Trauma-informed care in the UK: where are we? A qualitative study of health policies and professional perspectives. BMC health services research, 22(1), pp.1-12.

Geller, S., 2020. Cultivating online therapeutic presence: strengthening therapeutic relationships in teletherapy sessions. Counselling Psychology Quarterly, 34(3-4), pp.687-703.

Harris, M. & Fallot, R.D. 2001. Envisioning a trauma-informed service system: A vital paradigm shift. New Directions for Mental Health Services, 2001 (89), 3–22.

Huang, L.N., Flatow, R., Biggs, T., Afayee, S., Smith, K., Clark, T. and Blake, M., 2014. SAMHSA's Concept of Trauma and Guidance for a Trauma-Informed Approach. US Department of Health and Human Services.

Isobel, S., 2021. Trauma‐informed qualitative research: Some methodological and practical considerations. International Journal of Mental Health Nursing, 30, pp.1456-1469.

Langballe, Å. and Schultz, J.H., 2017. ‘I couldn’t tell such things to others’: trauma-exposed youth and the investigative interview. Police Practice and Research, 18(1), pp.62-74.

Lewis, C.L., Langhinrichsen-Rohling, J., Selwyn, C.N. and Lathan, E.C., 2019. Once BITTEN, twice shy: an applied trauma-informed healthcare model. Nursing Science Quarterly, 32(4), pp.291-298.

Risan, P., Milne, R. and Binder, P.E., 2020. Trauma narratives: Recommendations for investigative interviewing. Psychiatry, Psychology and Law, 27(4), pp.678-694.

Saltmarshe, E. 2018. Using story to change systems. Stanford Social Innovation Review, 20, pp.2-18.

Sweeney, A., Filson, B., Kennedy, A., Collinson, L. and Gillard, S., 2018. A paradigm shift: relationships in trauma-informed mental health services. BJPsych advances, 24(5), pp.319-333.

Sweeney, A., Clement, S., Filson, B. and Kennedy, A. 2016. Trauma-informed mental healthcare in the UK: what is it and how can we further its development? Mental Health Review Journal, 21: pp.174–9

Women’s Aid. 2022. Are you listening? 7 Pillars for a survivor-led approach to mental health support. Bristol: Women’s Aid