Most people experiencing addiction have had traumatic experiences in their lives. Trauma can cause a range of effects by disrupting a person’s sense of self, the way in which they navigate the world and the way they function. They may experience depression and anxiety and struggle to manage their emotions, build healthy relationships or trust others. People who experience trauma are at risk of developing serious mental health conditions including post-traumatic stress disorder. Using drugs and alcohol can help to numb the difficult and overwhelming symptoms related to trauma, but over time this puts these individuals at risk of addiction. Some describe substance use as a means of self-medication.
High quality drug and alcohol treatment can improve and save lives. Such treatment needs to be flexible, depending on the individual’s needs – service users should be treated with respect, listened to, receive timely mental health support, have a say in their treatment and feel safe and secure with staff from their treatment provider. This is particularly relevant for those who have had traumatic experiences, as addiction treatment may be daunting and difficult, with the potential to be retraumatising. Services should ensure risks of traumatisation are minimised – the UK clinical guidelines for drug and alcohol treatment (the ‘orange book’) advocates an approach that aims to achieve this, referred to as trauma-informed care.
Trauma-informed care is not necessarily about treating the trauma or being aware of what has happened. Instead, it’s about adopting methods and principles that acknowledge and account for the fact someone may have had traumatic experience(s). This is done by understanding the effects of trauma and the impacts it may have on people. For example, trauma could cause people to become defensive and aggressive, or they may disengage and withdraw, or have difficulties trusting the intentions of professionals.
The key principles of trauma-informed care therefore are to reduce re-traumatisation and improve treatment experience and engagement. These principles aim to create trustworthiness, safety, empowerment, choice and collaboration.
A masters project undertaken by Fleur Gill and supported by Lee Collingham, Charlotte Dack and Jenny Scott at the University of Bath interviewed 15 people with experience of using drug and alcohol treatment services. Twelve men and three women took part – the youngest was 30 and the oldest 68 with an average age of 46. Their experience of treatment services ranged from five to 30 years, with an average of 17 years, although we didn’t capture this information from five of them.
The study had the aim of understanding whether they had experiences of trauma-informed care within their treatment, and whether they felt this affected their engagement. We used the key principles of trauma-informed care to write the questions, so we could gauge if people’s accounts of their treatment experience seemed to embed a trauma-informed approach. The research also aimed to provide insight into reasons for missed appointments, which is an ongoing issue within drug and alcohol services across the UK and may be linked to a lack of trauma-informed care.
The research found that despite guideline recommendations, most people interviewed had not experienced consistent trauma-informed care. Many felt that they had had little control over their treatment, with a power imbalance between them and the service.
‘I never felt I had any power within any services. I thought they had that piece of blue paper, which was very powerful – the script.’
Many also felt that their mental health needs were not acknowledged or treated, and that their appointments lacked true purpose and meaning, with a sense of superficiality that impacted on their motivation and willingness to engage.
‘He does all that “How you feeling, how’s life” and stuff, but I think it’s just become a case of “yes, no, ok, see you next month”.’
Most participants described missing appointments through forgetting to attend, feeling too intoxicated from using or having other commitments. However, they also described feeling that the appointments weren’t important to them because of this perceived superficiality and ‘tick box’ approach.
‘Would I forget if I thought it was REALLY important? Would I still forget it?… I’ve just got to go in for five minutes say “Yeah, I’m fine” and walk out again, and it’s not gonna be much motivation for me to try and remember.’
The relationship with the professionals delivering treatment, regardless of how trauma-informed their care sounded, was important. A good relationship included feeling listened to, not being judged, feeling like they were given time, feeling empathy and for some, feeling the key worker ‘went the extra mile’. A good relationship with their key worker meant they were more likely to want to attend.
‘My last key worker, I believe if it wasn’t for her I wouldn’t be where I am today… She showed me empathy and support, but I’ve had some where they’ve felt like a bit of a number.’
However, there were consistent mentions of differences among professionals with regards to their approaches and levels of understanding. Many felt that some professionals still seem to display a lack of compassion or understanding towards addiction, despite working in the field.
‘I can remember the first time I went there he literally said, “Well just don’t use drugs” and I’m like, “You tell me how to do that then!”, cos it’s not that simple.’
Most participants mentioned how much they value staff members with lived experience, and while there is consistent evidence in published studies of the benefits of having staff with lived experience, some services are known to still adopt an approach where staff don’t disclose their experiences.
‘I’ve always found it’s when I’ve had drug workers or whatever who’ve been there and done it, who’ve got experience, they’re always better than the ones who are just textbook.’
In this study we found accounts that seemed inconsistent with trauma-informed care and we also found that positive relationships with key workers, where the client felt listened to, respected and understood, encouraged attendance. Variability among the approaches and attitudes of professionals, and their levels of understanding of addiction, was an important influence on whether the person engaged with appointments.
The benefits of staff with lived experience in supporting meaningful engagement was a key message in these interviews. By supporting more openness and honesty between staff and service users and hiring more people with lived experience, we may increase trustworthiness, safety, empowerment, choice and collaboration in treatment – key underpinning tenets of trauma-informed care.
Our study chimes with the findings of the second part of the Carol Black review, and the need for services to reorientate their approaches to enable people to engage. Finally, it’s important to say that the type of study we did is focused on understanding people’s experiences rather than generalising about the experiences of all who use drug and alcohol services. A larger study would be needed to discover if what we have found is true on a wider and more general scale.
Fleur Gill is an MSc student with an interest in addiction research; Lee Collingham is an expert by experience who supported the research project; Charlotte Dack is a lecturer at the University of Bath; Jenny Scott is a senior lecturer at the University of Bath