Trauma-Informed Practice improves care and promotes safety at Forensic Psychiatric Hospital

By Carol Swan

More than three quarters of Canadians report they’ve experienced some potentially traumatic event in their lifetimes.  At the Forensic Psychiatric Hospital in Coquitlam, BC, researchers found that ALL of the hospital’s patients had experienced some form of trauma and many reported multiple childhood adversities and victimization or violence across their lifetimes.

“Trauma” is defined by the BC Ministry of Health as “an experience that overwhelms an individual’s capacity to cope”. Since the ministry released its Trauma-Informed Practice Guide in 2013, BC Mental Health and Substance Use Services (BCMHSUS), the agency responsible for the Forensic Psychiatric Hospital (FPH), the Burnaby Centre for Mental Health and Addiction and other adult mental health and substance use program, has introduced a trauma-informed approach.

“At the hospital we care for people involved with the criminal justice system who have been found Not Criminally Responsible Due to Mental Disorder,” says Angela Draude, the hospital’s Executive Director. “This can be a challenging patient population, but when we operate with the assumption that patients have some form of trauma in their backgrounds we can approach them with more understanding.”

Research shows that the majority of the hospital’s patients, 67 per cent, have experienced four or more traumatic events in childhood and adulthood. A history of more than four events is seen as a “tipping point” for a significant increase in mental, physical and lifestyle problems.

BC Ministry of Health Substance Use Services’ patients expressing themselves through art as a way to work on their emotional healing, awareness and development.

“Trauma-informed care is much like taking universal precautions to prevent infections – we always need to take trauma into consideration,” says Dr. Tonia Nicholls, a professor in psychiatry at UBC who is co-leading the research at BCMHSUS.

The awareness that so many patients have experienced trauma has had a profound impact on how the hospital delivers care. BCMHSUS’ trauma-informed practice steering committee includes a working group dedicated to using a trauma-informed approach at the hospital.

The hospital takes a “four pillar” approach to trauma-informed practice. The first pillar involves building awareness of how common it is to have traumatic experiences.  Last year, BCMHSUS hosted a workshop on how to bring a trauma-informed, compassionate lens to interactions with patients and colleagues. Dr. Maggie Bennington-Davis, chief medical officer for Health Share of Oregon, presented on the importance of brain health in infancy and childhood, the implications of the Adverse Childhood Experiences Study, as well as strategies for lowering stress and heart rates,  building resilience, and ensuring safety for clients, physicians and staff.

The second pillar emphasizes safety and trustworthiness. Dr. Nicholls says this is especially important when working with clients with a trauma history because they have often experienced unsafe relationships and living situations which can make it difficult for them to trust others.

“It’s important to follow through. Do what you say you will do, when you say you will do it. Be consistent and predictable in meeting appointments and expectations,” says Dr. Nicholls. “If you’re not trustworthy it can reinforce a client’s damaging belief that they don’t matter.”

The third pillar is to offer the opportunity for choice, collaboration and connection. This is put into action by engaging patients in decisions about their care and trying to create a non-hierarchical and supportive atmosphere.  Care providers who recognize their own triggers can role model emotional intelligence for patients.  At FPH, there are ongoing discussions with patients about what might upset them and how they can cope.  At the intake assessments, nurses ask patients about what sets them off and what helps them to ground themselves.

The fourth pillar is about building strengths and skills. Clients with a history of trauma often experience self-loathing and guilt. A trauma-informed approach helps them to identify their strengths and build resilience. For example, BCMHSUS uses a tool called the Short-Term Assessment of Risk and Treatability (START) to assess patients. Unlike traditional approaches to risk assessment, the START considers the patient’s strengths as well as risk factors.

A trauma-informed approach, combined with a clinical program redesign, has led to a notable decline in the use of seclusion for psychiatric patients. The Canadian Patient Safety Institute sees seclusion as a last resort to control behaviour in an emergency. The rate of seclusion per 1,000 patient days at FPH has dropped from 88 to 58 in the past three years. The number of new episodes of seclusion has dropped from 70-80 new seclusions a month in 2015/16 to an average of about 40 a month in 2016/17, with further reductions expected.

At the same time, staff safety is also improving. Over the last few years, violent injuries resulting in time loss WorkSafe BC claims have been reduced from 94 in 2015 to a forecasted estimate of 54 by the end of 2017. These improvements are seen as a result of the hospital’s approach to care and preventative measures established with management and union representatives.

BCMHSUS, an agency of the Provincial Health Services Authority, integrates trauma-informed practice in all of its services, including all of its adult mental health and substance use programs. It will also bring a trauma-informed approach to the provincial prison system as it begins to provide health services at all BC provincial correctional centres on October 1, 2017.

Carol Swan is the Communications Manager, BC Mental Health and Substance Use Services.