Adult Mental Health Services

Information Pack

Introduction to Trauma-
Informed Approaches
to mental healthcare

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What is this manual about?

This is a trauma-informed manual developed to support people using our services.

This initial part of the manual comprises an introductory information pack,

which will introduce you to:

• what we mean by trauma and adversity

• the effects of trauma and adversity
• an overview of trauma-informed approaches to mental health care.

The remaining parts of the manual comprise individual stabilisation workbooks,

which have been designed to support you in coping with the difficulties you may
face on a day-to-day basis.

Parts of this manual may be helpful for you and other parts may not. However, we really
hope that everyone will be able to find something in the manual that fits their situation
and can be useful in supporting them to move forward.

This manual has been developed with permission from the Cwm Taf Morgannwg
University Health Board, Psychology Therapies Team, Stabilisation Pack. If you want
to check out their manual too, it is readily accessible online here:
https://cwmtafmorgannwg.wales/services/mental-health/stabilisation-pack

Introduction to trauma and adversity

If we want to understand the reasons for mental health problems, it often makes more
sense to ask “What has happened to you?” rather than “What is wrong with you?”

It is very common for people who use mental health services to have been through
difficult life events. Research has shown that experiencing traumatic and / or adverse
life events can place individuals at higher risk of a range of health and social difficulties
(WHO, 2014). It may not have always been recognised or acknowledged, even by you,
that difficult life events might have contributed to your current difficulties. However, from
a trauma-informed perspective, mental health difficulties are understood to develop in
response to people’s life experiences.
 What do we mean by trauma and adversity
For many people, we may have not considered their past experiences as traumas
or traumatic events, and ‘trauma’ may not be a word you want to use to describe past
experiences you have encountered.

However, from a trauma-informed approach, any experience that leaves a person

feeling overwhelmed, scared and / or alone can be thought of as traumatic, even if it
did not involve physical harm. If a person’s survival, well-being, sense of themselves
or the future was threatened, then we can think about that event as a trauma.

Adversity is another word that can be used to describe a range of difficult experiences
that someone may have encountered in their life. The word adversity is often associated
with a broader range of difficult experiences that may affect people’s wellbeing. Often,
these are background situations and contexts that may not be viewed as ‘traumas’
but which can gradually wear down your ability to cope. They might include things like
struggling to feed your family, facing discrimination, living in insecure housing, or having
a very stressful job.

Sometimes people prefer to use the word adversity over trauma when thinking about
their experiences, and it’s important to use the language you feel comfortable with.
Within this manual we will use the words trauma and adversity interchangeably
to refer to any experience that may have been difficult.

Below are some examples of traumatic and adverse experiences that have been
shown to have a negative effect on wellbeing:

• Childhood abuse (emotional, physical, • Accidents or injuries

sexual or neglect) • Physical ill health
• Poverty • Parental separation or relationship
• Domestic violence (being abused breakdown
or witnessing abuse) • The loss of a job
• Bullying • Feeling unable to meet the expectations
• Physical assault, such as a stabbing placed on you by family, friends
or robbery or society
• Housing instability • Feeling excluded because an aspect
• Migration of your identity (perhaps your gender,
ethnicity, or age) is not valued by others
• Discrimination
• Not having the power or confidence
• Sexual violence to decide on the values and meanings
• Natural disasters, such as earthquakes that are important to you.

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How does experiencing trauma and adversity affect people?

Experiences of trauma and adversity will affect different people in different ways. What
one person finds distressing may be of less significance to others. This may be because
of someone’s individual personality, beliefs, values and previous experiences. It may also
depend on how others reacted and what kind of support, if any, you had at the time.

Everyone will experience some kind of adversity in their life that is bound to be upsetting
at the time, but these effects don’t necessarily need to be long-lasting. For example, it is
normal to feel shaky, tearful and frightened for several days or weeks after an assault,
but if you can talk to a friend or family member and be supported, you are much more
likely to be able to put the event behind you and get on with your life.

Sometimes, however, it is less possible to cope with the effects of trauma and adversity,
and research has shown that these experiences can have a very serious impact on
people’s mental health. We know that experiencing more frequent and severe traumatic
(and / or adverse) events can lead to higher levels of distress. Adversity and trauma are
also more likely to have long-lasting and detrimental effects if the events go on for a
longer period of time, are repeated, and we don’t have people around to believe,
protect and support us.

Trauma responses
Experiencing adversity or trauma in our lives can affect the way we think, feel, behave
and relate to others in various ways. There is no right or wrong way to be affected by
trauma – our reactions and responses will always be understandable when looked at
in the context of what has happened (or may still be happening) in our lives.

Overleaf are some examples of different ways that people may respond to adverse
experiences. Some of these terms, such as fight / flight / freeze, are explained in
other manuals.
 Possible responses
Adverse experience Impact (ways of coping)
• Repeated criticism from others Strong, • Cutting off (dissociating) from the difficult
• Abuse frightening and thoughts, feelings or memories
overwhelming • Self-harm as a way of controlling difficult emotions
• Neglect
emotions such
• Racism • Binge eating as a way of self-soothing and
as fear, anger
temporarily eliciting more pleasant feelings
• Homophobia or shame
• Psychotic or manic states as a way of cutting off
and escaping to a different reality
• Alcohol or drug use in attempt to forget and cut off

• Accident Physical danger • Fight / flight / freeze response

• Assault • Being highly aroused and alert in the body
• Natural disaster • Difficulty sleeping or switching off
• Abuse • Aggression or self-isolation as a way of
• Violence protecting oneself
• Suspicious thoughts (‘paranoia’)

• Being controlled by others in Lack of control • Engaging in rituals (e.g. excessive cleaning,
relationships needing to complete actions in a certain order)
• Poverty • Attempting to dominate others in relationships
• Loss of work / employment • Controlling food / self-starvation
• Behaving in a submissive way – finding it hard
to take back control

• Death / loss of a parent Disruption to • Trying too hard to please others

• Violence in the family home relationships • Using sexuality to gain control, love or attention
and attachments
• Separation from a partner • Being overly hard on yourself / self-critical
• Bullying • Finding it difficult to trust others in relationships

• Unable to meet family / Low self-esteem • Perfectionism

societal expectations (e.g. / negative • Unusual beliefs
struggling to find employment, sense of self
• Overworking
not living in line with the
expectations of the dominant • High moods (‘mania’)
social / cultural group) • Grandiosity
• Bullying • Self-criticism
• Difficulty making friends

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The trauma responses and possible ways of coping outlined on page 6 have been
adapted from the Power Threat Meaning Framework (Johnstone & Boyle, 2018).

You will notice that some of these ways of coping, such as hearing voices or having
extreme mood swings, are usually described as symptoms of mental illness.
A trauma-informed perspective sees them rather differently. Within this approach,
they are seen as survival responses – in other words, ways of coping with threatening
and emotionally overwhelming situations. For example, we may want to control our
eating if everything else in our life feels out of control, or we may be constantly tense
and on edge because as a child we witnessed domestic abuse.

These ways of coping are understandable when we know the full context. However,
they can become a problem in their own right. Sometimes we need help to come to
terms with a difficult past situation, or change a difficult present situation, so that we
can gradually let go of survival strategies that are no longer useful to us.

For more detailed information on a range of different mental health difficulties (including
dissociation, hearing voices, flashbacks and nightmares, mood swings, self-harm,
shame, and unusual beliefs) and how they may relate to experiences of trauma and
adversity, we recommend reviewing the Cwm Taf Information Pack here:
https://cwmtafmorgannwg.wales/services/mental-health/stabilisation-pack
 Trauma-informed approaches to recovery
We now know a great deal about how to support people to recover from trauma
and adversity.

It can be useful to think about recovery in three phases:

Phase one:  S tabilisation – education about the impact of difficult life experiences /
trauma on mental health, learning to cope with the impact (mental
health difficulties) and keeping safe.

Phase two:  T alking about, processing and coming to terms with what has
happened in the past.

Phase three: T aking up life again and moving forward from difficult past experiences.

This manual is mainly about Phase one – Stabilisation. In times of distress – when
people are experiencing difficulties with their mental health – things can often feel very
up and down (‘unstable’) and this can make it hard to move forward. Psychological
Stabilisation is the process of learning and putting into practice a range of different skills
and strategies to support you to manage distress more easily. It’s all about learning
to cope, keeping safe, gaining stability and control.

The ten stabilisation workbooks in this manual will introduce you to a range of different
skills and strategies. They are all small skills, and alone, won’t be able to fix big
problems. What they will be able to support you with is gaining a little more stability
and control of the difficulties you may be experiencing, which in turn we hope will
make it easier to start moving forwards towards recovery.

The three phases of recovery (outlined above) are not completely separate from each
other. Learning how to cope with the effects of trauma (phase one) is likely to involve
talking a bit about what happened. Talking about upsetting events (phase two) may
mean re-visiting some ways of coping (phase one). However, it is essential that you are
able to keep yourself safe and develop some ways of coping before you start to look at
traumas more closely.

It is important to note that some people do not want to talk about traumatic events at all.
They may be able to use some of the ideas and coping methods in the manual to feel
better, and not want to go any further. This is fine. It is always your decision. If after using
this manual to support you to cope and feel a bit better you would like to do some work
on your past experiences, staff can advise you on the different options for further support.

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What’s in the manual?

An outline of all the resources included in the manual has been provided below:

Information Pack (this session)

Introduction to the Trauma-Informed Approaches (TIA) to mental health care

Stabilisation Workbooks
To introduce you to a range of coping ideas and strategies for managing mental
health difficulties:

1.  2.  3.  4.  5. 
Adult Mental Health Services Adult Mental Health Services Adult Mental Health Services Adult Mental Health Services Adult Mental Health Services
Stabilisation Workbook 1 Stabilisation Workbook 2 Stabilisation Workbook 3 Stabilisation Workbook 4 Stabilisation Workbook 5

Developing self- Soothing and safety: Mindfulness: Effective communication: Breathing and
compassion: Learning Learning to calm and Learning to be in Learning to be as relaxation: Learning
to be kind to yourself soothe yourself the present moment effective as possible to calm my body
when communicating

1 1 1

1. Developing 2. Soothing 3. Mindfulness 4. Effective 5. Breathing

self-compassion and safety communication and relaxation

6.  7.  8.  9.  10. 
Adult Mental Health Services Adult Mental Health Services Adult Mental Health Services Adult Mental Health Services Adult Mental Health Services
Stabilisation Workbook 6 Stabilisation Workbook 7 Stabilisation Workbook 8 Stabilisation Workbook 9 Stabilisation Workbook 10

Food and sleep: Distraction and Valued activity: Grounding: Learning Maintaining
Attending to our distancing: Learning to Learning to engage with to connect myself with my wellbeing
basic needs step back from difficult what’s important to us my surroundings
thoughts and feelings

6. Food 7. Distraction 8. Valued activity 9. Grounding 10. Maintaining

and sleep and distancing my wellbeing
 Will it work for me?
Learning to cope with the effects of trauma and / or adversity is not easy. It needs time,
determination, and often support from others.

It is important to acknowledge that none of the strategies we introduce to you in the

workbooks that follow will work instantly, and they will all need practice. It takes time
to learn to manage distress more easily, and it is important to start off practicing the new
strategies at times when you are feeling as calm and safe as possible. This way they
will be easier to implement in times of need. With perseverance and determination,
and support from the people around you, you will start to find these strategies easier.
It is important to remember to praise yourself for every step you take along the way,
even the small ones.

It is also important to acknowledge that not all the resources in this booklet will be right
for you and that’s okay. It will be helpful to read through and practice as many of the
different strategies as you can in order to help you find the best combination that works
for you.

Recovery often happens in small steps, and sometimes things may get worse before
they get better. However, everyone does have the capacity to eventually recover and
move on in their lives. We wish you the best of luck with the manual and hope that
you can find it helpful.

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Interested in learning more?

If you want to start learning more about trauma-informed approaches to mental health
than we are able to cover in this manual, you will find a list of useful reading and
resources below.

Additional reading on trauma and adversity

• The Power Threat Meaning Framework, by Lucy Johnstone and Mary Boyle (2018)
• The Spirit Level: Why Equality is Better for Everyone, by Richard Wilkinson and Kate
Pickett (2010)
• www.acestoohigh.com
• The Body Keeps the Score, by Bessel Van Der Kolk (2015)
• Trauma and Recovery, by Judith Herman (1997)
• Breaking Free: Help for Survivors of Child Sexual Abuse, by Carolyn Ainscough
and Kay Toon (2000)
• Overcoming Traumatic Stress, by Claudia Herbert and Ann Wetmore (2002)

Acknowledgments
This manual has been developed from, credits and would like to thank the Cwm
Taf Morgannwg University Health Board – Psychological Therapies Department
Stabilisation Pack

This manual has been developed for CNWL by:

Faye Nikopaschos, Gail Burrell, Sheelagh Holmes, Nick Rhodes & Cleo Boado
Harrow Acute Mental Health Services (November 2020)
Central and North West London NHS Foundation Trust
 This manual has been developed by the Harrow TIA Team (Faye Nikopaschos,
Gail Burrell, Sheelagh Holmes, Nick Rhodes and Cleo Boado) from the Cwm Taf
Morgannwg University Health Board – Psychological Therapies Department
Stabilisation Pack

Central and North West London NHS Foundation Trust, ©

Central and North West London
350 Euston Road, Regent’s Place, London NW1 3AX NHS Foundation Trust
Tel: 020 3214 5700 www.cnwl.nhs.uk Ref: 1855_DEC2020 | December 2020
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