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A paradigm shift: relationships in trauma-informed mental health services

  • Angela Sweeney (a1), Beth Filson (a2), Angela Kennedy (a3), Lucie Collinson (a4) and Steve Gillard (a5)...


Trauma-informed approaches emerged partly in response to research demonstrating that trauma is widespread across society, that it is highly correlated with mental health and that this is a costly public health issue. The fundamental shift in providing support using a trauma-informed approach is to move from thinking ‘What is wrong with you?’ to considering ‘What happened to you?’. This article, authored by trauma survivors and service providers, describes trauma-informed approaches to mental healthcare, why they are needed and how barriers can be overcome so that they can be implemented as an organisational change process. It also describes how past trauma can be understood as the cause of mental distress for many service users, how service users can be retraumatised by ‘trauma-uninformed’ staff and how staff can experience vicariously the service user's trauma and can themselves be traumatised by practices such as restraint and seclusion. Trauma-informed mental healthcare offers opportunities to improve service users' experiences, improve working environments for staff, increase job satisfaction and reduce stress levels by improving the relationships between staff and patients through greater understanding, respect and trust.


  • Appreciate broad-based definitions of trauma

  • Gain an understanding of what trauma-informed approaches are and why they have emerged, including the potential for (re)traumatisation in the mental health system

  • Consider how to practise trauma-informed approaches, including in ‘trauma-uninformed’ organisations, and the potential barriers to and opportunities from doing so


A. S. is funded by a National Institute for Health Research (NIHR) Post-Doctoral Fellowship. This article presents independent research partially funded by the NIHR. The views expressed are those of the authors and not necessarily those of the National Health Service, the NIHR or the Department of Health.

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This is an Open Access article, distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives licence (, which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is unaltered and is properly cited. The written permission of Cambridge University Press must be obtained for commercial re-use or in order to create a derivative work.

Corresponding author

Correspondence Dr Angela Sweeney, St George's, University of London, Population Health Research Institute, Cranmer Terrace, London SW17 ORE, UK. Email:


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Against Violence and Abuse, Agenda Alliance for Women and Girls (2017) The Core Components of a Gender Sensitive Service for Women Experiencing Multiple Disadvantage: A Review of the Literature. AVA.
American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders (5th edn) (DSM-5). American Psychiatric Publishing.
Baker, C, Shaw, C, Biley, F (eds) (2013) Our Encounters with Self-Harm. PCCS Books.
Barry, H, Hardiman, O, Healy, DG, et al. (2011) Anti-NMDA receptor encephalitis: an important differential diagnosis in psychosis. British Journal of Psychiatry, 199: 508–9.
Blanch, A, Filson, B, Penney, D, et al. (2012) Engaging Women in Trauma-Informed Peer Support: A Guidebook. National Centre for Trauma-Informed Care.
Bloom, S (1995) Creating sanctuary in the school. Journal for a Just and Caring Education, 1: 403–33.
Bloom, S (2006) Human Service Systems and Organizational Stress: Thinking and Feeling Our Way out of Existing Organizational Dilemmas (Report for the Trauma Task Force). Community Works.
Bowers, L, James, K, Quirk, A, et al. (2015) Reducing conflict and containment rates on acute psychiatric wards: the Safewards cluster randomised controlled trial. International Journal of Nursing Studies, 52: 1412–22.
Brophy, L, Roper, C, Hamilton, B, et al. (2016) Consumers’ and their supporters’ perspectives on barriers and strategies to reducing seclusion and restraint in mental health settings. Australian Health Review, 40: 599604.
Butler, LD, Critelli, FM, Rinfrette, ES (2011) Trauma-informed care and mental health. Directions in Psychiatry, 31: 197210.
Cusack, P, Cusack, FP, McAndrews, S, et al. (2018) An integrative review exploring the physical and psychological harm inherent in using restraint in mental health inpatient settings. International Journal of Mental Health Nursing, 27: 1162–76.
Elliot, D, Bjelajac, P, Fallot, R, et al. (2005) Trauma-informed or trauma-denied: principles and implementation of trauma-informed services for women. Journal of Community Psychology, 33: 461–77.
Elwyn, G, Frosch, D, Thomson, R, et al. (2012) Shared decision making: a model for clinical practice. Journal of General Internal Medicine, 27: 1361–7. doi:10.1007/s11606-012-2077-6.
Esaki, N, Larkin, H (2013) Prevalence of adverse childhood experiences (ACEs) among child service providers. Families in Society, 94: 31–7.
Felitti, G, Anda, R, Nordenberg, D, et al. (1998) Relationship of child abuse and household dysfunction to many of the leading causes of death in adults: the Adverse Childhood Experiences (ACE) study. American Journal of Preventive Medicine, 14: 245–58.
Filson, B (2011) Is anyone really listening? National Council Magazine, (2): 15.
Filson, B (2013) Self-Injury: The Attempt to Cope, Connect and Communicate. Webinar for MA Department of Public Health – Suicide Prevention Bureau and the National Association of State Mental Health Program Directors (
Filson, B (2016) The haunting can end: trauma-informed approaches in healing from abuse and adversity. In Searching for a Rose Garden: Challenging Psychiatry, Fostering Mad Studies (eds Russo, J, Sweeney, A): 20–4. PCCS Books.
Frances, A (2013) Saving normal: an insider's revolt against out-of-control psychiatric diagnosis, DSM-5, big pharma and the medicalization of ordinary life. Psychotherapy in Australia, 19(3): 14–8.
Freuh, C, Knapp, R, Cusack, K, et al. (2005) Patients’ reports of traumatic or harmful experiences within the psychiatric setting. Psychiatric Services, 56: 1123–33.
Friedman, MJ (2013) Finalizing PTSD in DSM-5: getting here from there and where to go next. Journal of Traumatic Stress, 26: 548–56.
Gillard, S, Edwards, C, Gibson, S, et al. (2013) Introducing Peer Worker roles into UK mental health service teams: a qualitative analysis of the organisational benefits and challenges. BMC Health Services Research, 13: 188.
Grundy, AC, Bee, P, Meade, O, et al. (2016) Bringing meaning to user involvement in mental health care planning: a qualitative exploration of service user perspectives. Journal of Psychiatric and Mental Health Nursing, 23: 1221.
Hatch, S, Dohrenwend, B (2007) Distribution of traumatic and other stressful life events by race/ethnicity, gender, SES and age: a review of the research. American Journal of Community Psychology, 40: 313–32.
Hepworth, I, McGowan, L (2013) Do mental health professionals enquire about childhood sexual abuse during routine mental health assessment in acute mental health settings? A substantive literature review. Journal of Psychiatric Mental Health Nursing, 20: 473–83.
Herman, J (1998) Recovery from Psychological Trauma. Psychiatry and Clinical Neurosciences, 52: S98S103.
Jackson, V (2003) In our own voice: African-American stories of oppression, survival and recovery in mental health systems. Off Our Backs, 33(7/8): 1921.
Johnstone, L, Boyle, M, Cromby, J, et al. (2018) The Power Threat Meaning Framework: Towards the Identification of Patterns in Emotional Distress, Unusual Experiences and Troubled or Troubling Behaviour, as an Alternative to Functional Psychiatric Diagnosis. British Psychological Society.
Karatzias, T, Cloitre, M, Maercker, A, et al. (2018) PTSD and Complex PTSD: ICD-11 updates on concept and measurement in the UK, USA, Germany and Lithuania. European Journal of Psychotraumatology, 8(suppl 7): 1418103.
Kessler, RC, McLaughlin, KA, Green, JG, et al. (2010) Childhood adversities and adult psychopathology in the WHO World Mental Health Surveys. British Journal of Psychiatry, 197: 378–85.
Khalifeh, H, Moran, P, Borschmann, R, et al. (2015) Domestic and sexual violence against patients with severe mental illness. Psychological Medicine, 45: 875–86.
Knight, C (2015) Trauma-informed social work practice: practice considerations and challenges. Clinical Social Work Journal, 43: 2537.
Levine, P (2010) In an Unspoken Voice: How the Body Releases Trauma and Restores Goodness. North Atlantic Books.
Mauritz, M, Goossens, P, Draijer, N, et al. (2013) Prevalence of interpersonal trauma exposure and trauma-related disorders in severe mental illness. European Journal of Psychotraumatology, 4 (doi: 10.3402/ejpt.v4i0.19985).
McCrone, P, Dhanasiri, S, Patel, A, et al. (2008) Paying the Price: The Cost of Mental Health Care in England to 2026. King's Fund.
McHugh, P, Treisman, G (2007) PTSD: a problem diagnostic category. Journal of Anxiety Disorders, 21: 211–22.
Mead, S, McNeil, C (2006) Peer support: what makes it unique? International Journal of Psychosocial Rehabilitation, 10: 2937.
Mental Health Taskforce (2016) The Five Year Forward View for Mental Health: A Report from the Independent Mental Health Taskforce to the NHS in England (February 2016). Mental Health Taskforce.
Mind (2013) Mental Health Crisis Care: Physical Restraint in Crisis. A Report on Physical Restraint in Hospital Settings in England. Mind.
Mohan, R, McCrone, P, Szmukler, G, et al. (2006) Ethnic differences in mental health service use among patients with psychotic disorders. Social Psychiatry and Psychiatric Epidemiolgy, 41: 771–6.
Morgan, C, Mallett, R, Hutchinson, G, et al. (2004) Negative pathways to psychiatric care and ethnicity: the bridge between social science and psychiatry. Social Science and Medicine, 58: 739–52.
Muskett, C (2014) Trauma-informed care in inpatient mental health settings: a review of the literature. International Journal of Mental Health Nursing, 23: 51–9.
NHS Digital (2016) Adult Psychiatric Morbidity Survey: Survey of Mental Health and Wellbeing, England, 2014. NHS Digital ( Accessed 3rd April 2018.
NHS Education for Scotland (2017) Transforming Psychological Trauma: A Knowledge and Skills Framework for the Scottish Workforce. Scottish Government.
NHS England (2016) Implementing the Five Year Forward View for Mental Health. NHS England.
Norvoll, R, Pedersen, R (2016) Exploring the views of people with mental health problems on the concept of coercion: towards a broader socio-ethical perspective. Social Science and Medicine, 156: 204–11.
O'Hagan, M, Divis, M, Long, J (2008) Best Practice in the Reduction and Elimination of Seclusion and Restraint. Seclusion: Time for Change. Te Pou Te Whakaaro Nui: The National Centre of Mental Health Research, Information and Workforce Development.
Örmon, K, Hörberg, U (2017) The unnecessary suffering and abuse caused by healthcare professionals needs to stop: a study regarding experiences of abuse among female patients in a general psychiatric setting. Clinical Nursing Studies, 5: 5964.
Powers, A, Cross, D, Fani, N (2015) PTSD, emotion dysregulation, and dissociative symptoms in highly traumatized sample. Journal of Psychiatric Research, 61: 174–9.
Priebe, S, McCabe, R (2008) Therapeutic relationships in psychiatry: the basis of therapy or therapy in itself? International Review of Psychiatry, 20: 521–6.
Public Health Wales (2015) Adverse Childhood Experiences and Their Impact on Health-Harming Behaviours in the Welsh Adult Population. Public Health Wales NHS Trust.
Raju, R, Corrigan, FM, Davidson, AJW, et al. (2012) Assessing and managing mild to moderate emotion dysregulation. Advances in Psychiatric Treatment, 18: 8293.
Read, J, Hammersley, P, Rudegeair, T (2007) Why, when and how to ask about childhood abuse. Advances in Psychiatric Treatment, 13: 101–10.
Read, J (2010) Can poverty drive you mad? ‘Schizophrenia’, socio-economic status and the case for primary prevention. New Zealand Journal of Psychology, 39(2): 719.
Read, J, Fosse, R, Moskowitz, A, et al. (2014) The traumagenic neurodevelopmental model of psychosis revisited. Neuropsychiatry, 4: 6579.
Read, J, Harper, D, Tucker, I, et al. (2017) Do adult mental health services identify child abuse and neglect? A systematic review. International Journal of Mental Health Nursing, 27: 719.
Rose, D, Trevillion, K and Woodall, A et al. (2011). Barriers and facilitators of disclosures of domestic violence by mental health service users: qualitative study. British Journal of Psychiatry, 198: 189–94. doi: 10.1192/bjp.bp.109.072389.
Rose, S, Freeman, C, Proudlock, S (2012) Despite the evidence – why are we still not creating more trauma informed mental health services? Journal of Public Mental Health, 11: 59.
Rouf, K, Waites, B, Weatherhead, S (2016) Guidance Document on the Management of Disclosures of Non-Recent (Historic) Child Sexual Abuse. British Psychological Society.
Schauben, L, Frazier, P (1995) Vicarious trauma: the effects on female counselors of working with sexual violence survivors. Psychology of Women Quarterly, 19: 4964.
Schouler-Ocak, M, Graef-Calliess, I, Qureshi, A, et al. (2015) EPA guidance on cultural competence training. European Psychiatry, 30: 431–40.
Scott, S, Williams, J, McNaughton Nicholls, C, et al. (2015) A Briefing for Commissioners. What Survivors of Violence and Abuse Say About Mental Health Services: Responding Effectively to Violence and Abuse (REVA Briefing 4). NatCen (
Shevlin, M, Housten, JE, Dorahy, MJ, et al. (2008) Cumulative traumas and psychosis: an analysis of the National Comorbidity Survey and the British Psychiatric Morbidity Survey. Schizophrenia Bulletin, 34: 193–9.
Siegel, DJ (1999) The Developing Mind: How Relationships and the Brain Interact to Shape Who We Are. Guilford Press.
Siegel, D (2012) Pocket Guide to Interpersonal Neurobiology: An Integrative Handbook of the Mind. W.W. Norton and Company.
Substance Abuse and Mental Health Services Administration (2014) SAMHSAs Concept of Trauma and Guidance for a Trauma-Informed Approach (HHS Publication No. (SMA) 14-4884). SAMHSA.
Sweeney, A, Fahmy, S, Nolan, F, et al. (2014) The relationship between therapeutic alliance and service user satisfaction in mental health inpatient wards and crisis house alternatives: a cross-sectional study. PLoS ONE, 9(7): e100153.
Sweeney, A, Clement, S, Filson, B, et al. (2016) Trauma-informed mental healthcare in the UK: what is it and how can we further its development? Mental Health Review Journal, 21: 174–92.
Toner, J, Daiches, A, Larkin, W (2013) Asking about trauma: the experiences of psychological therapists in early intervention services. Psychosis, 5: 175–86.
Van der Kolk, B (2003) The neurobiology of childhood trauma and abuse. Child and Adolescent Psychiatric Clinics of North America, 12: 293317.
Van der Kolk, B (2005) Developmental trauma disorder: towards a rational diagnosis for chronically traumatized children. Psychiatric Annals, 35: 401–8.
Van der Kolk, B (2014) The Body Keeps the Score: Mind, Brain and Body in the Transformation of Trauma. Penguin Books.
Walters, S, Hogg, L, Gillmore, C (2015) Evaluation of a tailored training programme to improve the assessment and treatment of trauma in an Early Intervention in Psychosis service. Psychosis: Psychological, Social and Integrative Approaches, 8: 226–37.
Yehuda, R, Daskalakis, N, Bierer, L, et al. (2016) Holocaust exposure induced intergenerational effects on FKBP5 methylation. Biological Psychiatry, 80: 372–80.
Young, M, Read, J, Barker-Collo, S, et al. (2001) Evaluating and overcoming barriers to taking abuse histories. Professional Psychology: Research & Practice, 32: 407–14.


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A paradigm shift: relationships in trauma-informed mental health services

  • Angela Sweeney (a1), Beth Filson (a2), Angela Kennedy (a3), Lucie Collinson (a4) and Steve Gillard (a5)...


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