Developing a protocol for routine enquiry into childhood adversity
Research type
Research Study
Full title
The development of a protocol for routine enquiry into experiences of childhood adversity for clients attending a Primary Care Mental Health Team
IRAS ID
285202
Contact name
Mhairi Selkirk
Contact email
Sponsor organisation
NHS Greater Glasgow & Clyde
Duration of Study in the UK
1 years, 7 months, 30 days
Research summary
Research Summary
The project aims are to create a protocol for routine enquiry into experiences of childhood adversity within a Primary Care Mental Health Team. Clients attending the service participate in an initial assessment by telephone or in person. Clients are screened for experiences of childhood abuse during this assessment. However, methods of enquiry are likely to vary between practitioners.
The research will be conducted in two phases.
Phase 1
The first phase will involve individual semi-structured interviews with clients following the assessment process described above. The interviews will focus on their experiences of the assessment process and the factors they see as most relevant to their mental health, with a particular focus on experiences and perspectives of being asked about childhood adversity.
Focus groups with clinicians will also be conducted. The focus groups will explore views on routine enquiry, current methods of enquiry, understanding of the influence of experiences of childhood adversity on adult physical and mental health, and how this is influenced by different theoretical perspectives within mental health literature.Data will be analysed using Interpretative Phenomenological Analysis to identify key themes, with a view to establishing what enquiry methods are acceptable to clients, and how staff conceptualisations of clients’ difficulties are affected by frameworks surrounding routine enquiry methods.
Phase 2
Findings from phase 1, described above, will inform the development of a routine enquiry protocol. The protocol will be implemented for a period of six months. After the implementation phase, clients and staff will be invited to take part in a survey about their experiences. A subset will be invited to participate in individual interviews and focus groups to explore relevant issues in greater depth. The focus will be the acceptability of the routine enquiry protocol, and any influence on staff and clients’ understanding of presenting difficulties.
Summary of Results
This study sought to investigate staff and client views on routine enquiry into adverse childhood experiences in Primary Care Mental Health Teams (PCMHTs). The original intent was to develop a standardised protocol from this and evaluate this in a second phase of the research. However, Phase 2 was abandoned. This was partly due to recruitment delays associated with the Covid-19 pandemic. Further, the results from Phase 1 suggested that developing a tool as originally proposed may not be desirable, and that developing practice recommendations based on data analysis from Phase 1 would be more helpful. While sufficient numbers of participants were recruited in Phase 1, unfortunately the aforementioned delays meant that data analysis from the client arm of the study has not been concluded and is still underway. Results from the staff arm of the study are discussed below.
Six key themes were identified from staff focus groups: (1) professional identity; (2) public and professional discourse; (3) systemic context; (4) routine enquiry praxis; (5) routine enquiry as a skilful and emotive relational practice; and (6) ethical ambivalence.
PROFESSIONAL IDENTITY: Staff participants viewed routine enquiry into childhood adversity as a core part of their professional identity. They linked their practice in this regard to core therapeutic values focused on helping others and non-judgemental practice. The therapeutic relationship was characterised as different from other types of relationships, creating a safe and boundaried space in which clients could disclose distressing experiences. Participants discussed attending to and seeking to ameliorate power imbalances in interactions with clients. Routine enquiry into childhood adversity was generally seen as falling beyond the scope of practice of other types of health professionals, who were viewed as lacking the time, skills and training to conduct this sensitively.
PUBLIC AND PROFESSIONAL DISCOURSE: Therapists generally defined childhood adversity as incorporating a wide range of challenging experiences within families, communities, and broader society. Psychological theory was utilised to formulate the links between early life experiences and current difficulties, with an emphasis on attachment, social learning, cognitive behavioural, and compassion focused theories. Where therapists perceived gaps in their professional training, they tended to fill these through personal study, sometimes of biologically influenced models. Relationships were viewed as strongly influencing mental health, in both protective and detrimental ways. Trauma and adversity were thought to have differential effects depending on the social context and individual interpretations. The trauma-informed agenda and Adverse Childhood Experiences (ACEs) research were thought to have the potential to raise awareness of adversity at a systemic level. However, mainstream narratives relating to trauma were viewed as reductionist, pathologising and deterministic by some participants.
Participants considered that there had been an increase in public awareness of mental health and trauma, largely driven by the media, including social media. This was seen as having the potential to destigmatise traumatic experiences, potentially leading to greater ease of disclosure for clients. However, concerns were also raised that exposure to trauma-related material could result in distress for clients, or lead to them interpreting their experiences in a rigid and categorical manner.
SYSTEMIC CHALLENGES: Participants discussed working in a stressful and pressured service context, which was seen as busy and oversubscribed with insufficient staffing and resources. At times, services processes clashed with participants’ personal values, leading to a sense of devaluation and disempowerment which could result in stress and burnout. Other mental health services (such as Community Mental Health Teams) were characterised as having rigid boundaries, which participants linked to waiting times rather than client need. Secondary care mental health services were viewed as being aligned to medical models of distress, focused on risk, and dismissive of historical issues. Participants noted that transfers of care were often rejected, creating additional pressure for PCMHT staff. Routine enquiry was seen to function as a gatekeeping tool in this context where disclosures of trauma could rule clients in or out of different services.
The research was conducted during the Covid-19 pandemic at a time of rapid change in working practices to deliver psychological therapies remotely. Conducting routine enquiry into traumatic experiences was viewed as particularly challenging in this context. Participants discussed feeling isolated from their colleagues when working remotely. They perceived a greater congruence between their experiences and those of clients during the pandemic than would usually be the case, which increased the emotional demands of their work. While some participants suggested that remote working could help clients to access therapeutic services, others expressed strong views that this undermined the therapeutic process and their ability to attune to and regulate clients’ emotions.
ROUTINE ENQUIRY PRAXIS: Routine enquiry was described as an expectation of services. Most therapists viewed this as a relevant and important aspect of their work. An increased focus on trauma at a policy level was welcomed by some therapists. Approaches to routine enquiry were standardised within processes and paperwork within some teams, which most participants viewed as a helpful prompt. Some participants noted that routine enquiry had always been part of their practice, but perceived a greater emphasis on this over the last decade. However, others viewed a requirement for routine enquiry as an unwelcome imposition on their practice.
Routine enquiry was viewed as having potential therapeutic benefits for clients, allowing them to feel heard and validated. Participants favoured a naturalistic, contextualised approach to routine enquiry over structured and directive methods, which were viewed as ‘box ticking’. Some therapists discussed preparing clients for disclosure by requesting their consent to enquire about abuse and giving permission not to disclose. At times, reasoned decisions were made not to proceed with routine enquiry, mainly when clients appeared highly distressed or risk was identified. Detailed discussions of traumatic experiences were avoided at initial assessments to prevent clients from becoming emotionally overwhelmed.
ROUTINE ENQUIRY AS A SKILFUL AND EMOTIVE RELATIONAL PRACTICE: Routine enquiry was viewed as a highly skilled therapeutic endeavour requiring advanced training. Therapists discussed a broad range of non-specific therapeutic skills which they brought to this work. A part of the therapists’ role was defined as holding therapeutic boundaries and tolerating what clients brought to sessions, while intervening to regulate distress. Establishing a therapeutic relationship prior to routine enquiry was seen as important. Decisions about how and when to enquire appeared to be guided by subtle, implicit, heuristic reasoning based on past professional experience.
Routine enquiry was sometimes conceptualised as a relatively neutral activity which did not provoke negative reactions from clients, particularly if they had not experienced trauma. Some participants considered that clients might expect to be asked about traumatic experiences during mental health assessments. Nonetheless, it was suggested that some clients may feel obligated to answer questions about abuse due to power dynamics inherent in the interaction, even if they were not comfortable with this. Clients’ reactions were described as varied, with some expressing surprise or confusion when asked about their early life experiences. Some clients were noted to deny abuse and close off emotionally, particularly within initial appointments. Clients were perceived as keen to disclose abuse if this was congruent with their reasons for seeking therapy.
Routine enquiry was characterised as emotionally challenging work, particularly when hearing multiple abuse disclosures in close succession. Empathy was viewed as a core therapeutic skill, but one which could increase the impact of trauma disclosures. Given these emotional demands, support, reflection and supervision were highly valued. A sense of connection with colleagues allowed this work to feel like a shared experience. Informal conversations with colleagues in the aftermath of challenging sessions allowed participants to explore and process their emotional responses.
ETHICAL AMBIVALENCE: Routine enquiry was seen as excessively intrusive and unnecessary in some circumstances. Discussions about trauma and adversity was thought to increase the salience of these issues outside sessions, resulting in increased distress, which was viewed as especially problematic if followed by lengthy waits for therapy. Facilitating trauma disclosures was viewed as potentially unethical in situations where clients were referred onto other services following assessment, particularly if they had to repeat their experiences of trauma to multiple professionals. Some participants highlighted that there could be legal obligations to report past abuse which clients may not anticipate. This was seen as having the potential to change the role of the therapist from a caring helper to an authority figure making decisions on clients’ behalf which could be contrary to their wishes.
Therapists expressed concerns about the ethics of routine enquiry serving as a gatekeeping tool within a complex mental health system. Refusals to accept transfers of care due to limited capacity in secondary and tertiary care services was viewed as a harmful practice which could result in feelings of rejection and abandonment in clients who had experienced trauma and adversity. In turn, this resulted in feelings of guilt and responsibility for therapists.
In conclusion, the results of this study suggest that routine enquiry is seen as a central part of psychological therapists’ job role and professional identity. The nuances and complexities of this work were emphasised. Participants considered that advanced theoretical knowledge and therapeutic skills were necessary to conduct routine enquiry sensitively, and suggested that it may not be appropriate for staff within generic health services to undertake this work. Ethical concerns were raised about routine enquiry being used as a gatekeeping tool in busy and pressured mental health services in a way that was detrimental to client care. Experienced therapists had developed their own methods of enquiring about trauma and adversity based on past professional experience. Less experienced therapists may benefit from structured guidelines on how to enquire about trauma and adversity drawing upon the findings of this study.
REC name
West of Scotland REC 4
REC reference
21/WS/0086
Date of REC Opinion
9 Sep 2021
REC opinion
Further Information Favourable Opinion