Research and analysis

Trauma informed practice: learning from experience (accessible)

Published 30 January 2024

Applies to England and Wales

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Purpose

This document aims to share practice among violence reduction units (VRUs) and with sector partners for implementing programmes to develop and embed trauma-informed practice (TIP). There are 20 violence reduction units across England and Wales funded to bring together local partners to tackle the drivers of serious violence in their area. VRUs work with partners to develop a whole-systems approach which includes capacity building and delivering a range of early intervention and prevention programmes to divert children and young people away from involvement in serious violence.

The document is not a prescriptive or comprehensive list of requirements for implementation, nor is it formal ‘guidance’. TIP is often described as a ‘journey without a destination’ as it requires constant reflection and adaptation by practitioners and services to meet the needs of individuals, their specific histories, experiences and awareness of the wider circumstances which may contribute to their (re-)traumatisation. As such this document can only reflect what we have learned so far, and will likely need to be updated, reflected upon and adapted to suit different locations, organisations and services’ needs. Its aim is to help VRUs and partners learn from each other’s findings, ideas, and challenges.

In addition, the Home Office has funded research specifically into TIP, both by the Early Intervention Foundation (EIF - now merged with ‘What works for Children’s Social Care’ to form ‘Foundations’) and the Youth Endowment Fund (YEF). These evidence-based sources are invaluable and authoritative, and this document is intended to complement rather than duplicate information already covered.

If you are not already familiar with TIP, we recommend first looking at some of the pieces listed in the Resources section at the end of the document to enhance your understanding. Although a basic summary is included, the purpose of this document is not to define TIP, but rather draw practical lessons from its implementation by VRUs.

We would also like to thank those who have provided feedback on this document as it was being developed. In particular, Dr Kirsten Asmussen from Foundations, Hannah Wilson and Ediane Santana de Lima from Dartington Service Design Lab and colleagues from the YEF.

Methodology

The Home Office Trauma-Informed Policy Team (Leo Schwartz and Holly Sperling) within the serious violence reduction unit reviewed reports from VRUs alongside information gained through quarterly meetings. In these meetings we asked questions around programme delivery, looking for:

  • innovative or unusual intervention methods

  • how the model has been implemented

  • challenges faced at any stage in setup, implementation, or delivery, and mitigations that were used to counter these

  • lessons learned that can be applied to future trauma-informed programmes

  • risk / issue management, including identification and pre-issue mitigations

We also acquired programme knowledge and expertise from wider partners delivering TIP across Government and in different sectors and settings. Discussions during conferences have also informed our thinking, particularly the Trauma-Informed Policing Conference (1-2 November 2022) with VRUs, the National Police Chiefs’ Council, College of Policing, Office for Health Improvement and Disparities (OHID) and key sector partners including the Welsh ACE Support Hub and Scottish VRU.

This document is not produced in conjunction with the Youth Endowment Fund and is more focused on specific learnings from current VRU programmes rather than academic research. However, we encourage practitioners to keep up to date with the latest evidence and research through the YEF’s online Toolkit (see Resources section).

Intervention summary

Trauma-informed practice (TIP) is based on the understanding that trauma exposure can significantly impact both individuals’ development and life chances as well as the ability to feel safe or develop trusting relationships, and can also affect communities. TIP requires practitioners, organisations and systems to look beyond presenting behaviour and ask ‘what happened to this person?’ rather than ‘what is wrong with this person?’.

There are four key assumptions that underpin TIP, known as the 4 ‘R’s. An individual, programme, organisation, or system that is trauma-informed realises the impact that trauma can have; recognises the signs and symptoms of trauma (in both beneficiaries and professionals); responds to trauma by integrating knowledge of trauma into policies, procedures and practices; and seeks to actively prevent re-traumatisation by avoiding practices that could trigger painful and traumatic memories. In addition, there are six principles which inform TIP: Safety, Trust, Choice, Collaboration, Empowerment and Cultural Consideration (of individuals’ demographic characteristics).

The purpose of this document is not to define TIP, and several of the resources below set out comprehensive definitions, particularly those by Substance Abuse and Mental Health Services Administration (SAMHSA) (who developed the original definition), OHID, EIF and the Welsh ACE Support Hub.

Trauma-informed training

Trauma-informed (TI) training is only one element in the provision of trauma-informed practice (TIP) and should work alongside other components such as reflective practice, increasing access to therapeutic interventions and developing organisational policies. It is the most common TIP activity delivered by VRUs, and often the first stage of implementing TIP more broadly.

TI Training aims to improve practitioners’ knowledge, understanding and response to trauma. This might include:

  • understanding the impact of trauma

  • recognising the signs of trauma

  • skills related to interacting and responding to those who may have experienced trauma

  • avoiding practices which might lead to re-traumatisation

  • understanding the impact of vicarious or secondary trauma on practitioners (see Training content below)

The 2022 independent evaluation of VRUs found that the TI training delivered by VRUs was highly valued by partners, an example of good practice, and contributed to sustainably supporting a public health approach and effective multi-agency working. Partners considered TIP to be ‘highly effective in supporting (frontline) professionals to understand their role in the response to violence and upskill them to respond effectively’ (Violence reduction units, year ending March 2022 evaluation report, 3.2, February 2023).

On the basis of the research the Home Office commissioned from the EIF, ‘Understanding the potential of trauma-informed training in violence reduction units’, we suggest the strongest models of TI training are likely to:

  • integrate into broader efforts to implement trauma-informed practice, including systems and support mechanisms (such as support for staff wellbeing)

  • include training for senior staff as well as frontline practitioners (as this can increase buy-in and sustainability)

  • include content which clearly connects changes in knowledge to changes in practice (See Hampshire and West Midlands case studies below)

  • include follow-up activities or refresher training to reinforce learning

  • have a strong element of co-design: given the ambition to improve interactions and build trusting relationships between professionals and young people, involving both in the design of training content is likely to increase its ability to meet this objective

  • have well-developed quality assurance processes to ensure training is of a consistent quality: this is particularly important for ‘train the trainer’ courses (see ‘Train the trainer’ section below).

Trauma-informed practice

According to EIF’s report, TIP has the potential to contribute most to the wider system of support when it is delivered alongside well-evidenced interventions that have shown positive impact on young people’s outcomes.

From a broader systems perspective, VRUs should consider carefully how their trauma-informed programmes work alongside or integrate with other evidence-based interventions they are commissioning / delivering (such as focused deterrence, therapeutic interventions like CBT, or A&E navigator programmes as well as how the approach contributes to their role in supporting multi-agency working and systems leadership.

Trauma-informed practice is distinct from trauma-specific therapies such as trauma-focused cognitive behavioural therapy (TF-CBT) as it doesn’t seek to ‘treat’ trauma, rather to recognise it, create the conditions that will support healing more broadly and work in a way that prevents re-traumatisation (see Limitations of trauma-informed practice section).

Beyond training, the EIF has identified several components that VRUs may wish to consider when designing programmes, or thinking about how to implement TIP beyond increasing knowledge and awareness. One-off training alone (without changes to policies or practice) is unlikely to result in significant outcomes for end beneficiaries. Table 1 below sets out several different TIP components identified in children’s social care settings. However, TIP goes beyond these and should also be considered from the perspective of organisational values and culture.

Table 1: common components of trauma-informed care within children’s social care

Workforce development

Training of all staff on the impact of abuse or trauma

Measuring staff knowledge / practice

Strategies / procedures to address / stress (secondary trauma) among staff

Knowledge / skills in accessing evidence-based services

Defined leadership position for trauma services

Trauma-specific services

Use of standardised trauma screening / assessment measures *

Availability of evidence-based trauma-specific practices

Trauma history is always included in case / service plan

Organisational environments and practices

Within agency collaboration / service coordination

Outside agency collaboration / service coordination

Positive, safe physical environment

Reduce risk of retraumatisation

Strengths-based / promote positive development

Written policies that include trauma

(Adapted from Bunting et al., 2019)

Table 1 above, reproduced from EIF’s report ‘Trauma-informed care: understanding the use of trauma-informed approaches within children’s social care’, January 2022).

* Caution should be used regarding trauma screening tools (such as the ACE-Q) and these should not be used in place of comprehensive assessments, to triage or determine individuals’ access to support services.[footnote 1]

The YEF, in designing its TIP grant round (co-funded with the Home Office) identified the elements of TIP as follows:

1. Organisational learning: staff training and development which increase the awareness and knowledge of staff on the impact of trauma to support their own traumatic stress and adapt how they work with young people.

2. Organisational policies: changes to policies and ways of working that incorporate trauma, collaboration and information sharing within and across organisations, and support the development of safe, inclusive and positive environments.

3. Organisational processes: implementing trauma-focused referrals and planning such as access to trauma-specific services and the incorporation of trauma history in case/service plans.

Case study: Hampshire – trauma-informed practitioners

This pilot was the first of its kind in the UK and involved expert trauma-informed practitioners (TIPs) patrolling alongside Response and Patrol Teams in a live policing environment ti help them embed trauma-informed policing. This pilot, which operated in Hampshire and Isle of Wight Constabulary from Sept 2021 to March 2022, showed early indications of making a positive difference. The TIPs’ approach continues to receive significant national interest and has now been commissioned until 2025, evaluated by Liverpool John Moore’s University.

TIPs spend time getting to know the police teams and vice versa. They understand the challenges faced by Police and get a feel for Policing, going on patrol with officers, reviewing body worn video footage and safeguarding forms, observing people being booked into custody, and observing stop and search. The TIPs promote the use of Reflective Practice, providing an opportunity to de-brief incidents that Police and TIPs attend, and encouraging professional curiosity of the story behind the presenting behaviour. TIPs will produce de-personalised case studies to show-case the value of trauma-informed policing.

The TIPs help police recognise someone stuck in fight or flight mode and teach basic grounding techniques to help bring them back to the present moment. This can help overcome barriers in accessing support services often experienced by those affected by trauma. This consistent, trauma-informed way of working seeks to increase the likelihood of generating reachable/teachable moments and build feelings of safety and trust.

TIPs support includes the use of language and how powerful this can be. For example, using the appropriate language on a safeguarding form helps other professionals such as Social Workers in the Multi Agency Safeguarding Hub, and enables more appropriate support to be provided as a result. For instance, terms such as ‘refused to engage with support…’ can be replaced with ‘felt unable to accept support at this time because…’.

At the start of the TIPs pilot, the main impact of the TIPs was presumed to be on the ways officers respond to incidents and individuals. This did happen, with officers reporting increased awareness and sensitivity to the impact of trauma and the ways in which this can be mitigated in their responses and interactions. However, officer feedback also captured the project’s impact on officers’ general wellbeing and understanding of the impact of the work on themselves, with this becoming a key outcome.

Limitations of trauma-informed practice

Practitioners should be clear that TIP is not a replacement for specialist mental health services or intended to enable practitioners to ‘treat’ trauma or anyone with serious or diagnosed mental health conditions. Rather it should create the conditions for healing by encouraging appropriate referrals to specialist services, removing barriers to accessing support (including by developing trusted relationships), preventing re-traumatisation of the individual, recognising the impact of vicarious trauma on front-line staff and driving closer working and shared understanding between services.

While TIP is seen as a promising and innovative approach, practitioners should be aware that currently the evidence base in terms of its impact is under-developed. We hope to close this gap in the near future through the YEF and Home Office co-funded trauma-informed practice grant round and further research being carried out in other sectors. However, practitioners should be aware of the current evidence base, its limitations and where TIP is more or less likely to deliver outcomes for vulnerable children, young people and staff. This understanding should inform your programme design and Theory of Change.

Please refer to the literature review and Theory of Change from the EIFs research on VRUs’ TIP delivery to see which elements are currently more or less supported by evidence. The YEF’s Toolkit also contains information on common elements thought to be effective as well as information on the current evidence base.

Delivery Considerations

Qualifications, skills and experience

When choosing your delivery provider, careful attention should be paid to background qualifications, skills and experience of those who will be delivering the training. There are a range of different providers that can deliver trauma-informed training, from specialist organisations to voluntary and community sector organisations. Some VRUs also feel they have sufficient expertise within their own networks to deliver training internally. However, when choosing who will deliver your training you may wish to consider:

  • what level of qualification do they have in a relevant field such as psychology and have they continued to update their knowledge with recent relevant professional development courses?

  • whether they have an appropriate clinical or professional background so that they could effectively support someone who has had a traumatic experience and might be triggered by the training?

  • are they an experienced, professional trainer or educator?

  • are they experienced in delivering training to the specific cohort of professionals you are seeking to work with?

  • are they experienced in working with the end beneficiaries or the specific cohort you are seeking to benefit (children and young people at risk of involvement in serious violence)? Can they tailor the training and provide relevant examples in relation to this group and for professionals working with them on how implementing the training will work in practice?

  • if they have relevant lived experience, or will they be able to include elements of lived experience in the training? Are they able to represent the views and experiences of young people, ethnic minorities and those with other protected characteristics who may have particular (traumatic) experiences?

  • are there multiple trainers who can fulfil key criteria and deliver to the same standard in case one trainer is unable to complete all the delivery?

It may not be possible for one individual to fulfil all these criteria – they might need to be spread across a team of trainers delivering together.

Training content and length

Through the EIF Research, our observation of VRU trainings and reviews of delivery plans, we identified many different topics covered in training. These included:

  • ACEs and trauma, including what they are, their impact on a person or community, and how trauma affects the brain, physical, neurological and psychological development

  • recognising the signs of trauma, interacting and responding to those who may have experienced trauma

  • avoiding re-traumatisation

  • vicarious trauma and how to build resilience

  • how to apply the training in practice – what does a trauma-informed approach look, sound and feel like? How do you empower individuals through TI approach? Considering language and vocabulary from a TI perspective, and the importance of building trust

  • developing trauma-informed organisations, and how to embed a trauma-informed approach long-term

  • specific forms of trauma – community trauma, racial trauma, trauma specifically affecting the LGBTQ+ community, or those experiencing domestic abuse / violence against women and girls

VRUs have used varying lengths of training (from half a day to three days) and there is no definitive evidence that identifies how much time is needed for participants to significantly increase their knowledge and understanding. However, given the breadth and complexity of the topics above it is unlikely that short courses (for example, a few hours or half a day) will be sufficient. In addition, one-off trainings without follow-up support or consideration of how knowledge gained can be implemented in practice are less likely to achieve the desired outcomes.

Sector-specific considerations

The impact of the training may be different for different workforces. For example, training could be more likely to lead to improved practice within workforces where knowledge and understanding of the impact of trauma has not previously been addressed, rather than those who are already familiar with these concepts. Sectors such as healthcare or social work may be more used to TIP (although not always badged as such) and be closer to embedding its principles within their standard practices than sectors such as policing or education.

Decisions about who to train, where and when, should be determined by the outcomes that the training is designed to achieve. If the primary aim is to develop a common understanding among frontline practitioners working with children and young people at risk of serious youth violence, then including all relevant practitioners is important. In the research conducted by EIF, VRUs strongly emphasised the value of the shared language and understanding that was perceived to result from training multiple workforces. If, however, the aim is more about improving practice and engagement with vulnerable young people, then it may be more effective to focus on those workforces where the greatest change is sought.

Consideration should also be given to support functions as well as frontline practitioners. For example, administrative staff may need to be aware of the impact of trauma in order to avoid triggers and re-traumatisation as these act as barriers to accessing support and services.

Involving stakeholders from the sector(s) you intend to train in the co-design process should also ensure the training is more bespoke and help to identify specific examples of how the knowledge gained during training can support changes in practice.

Location-specific considerations

Carefully consider any barriers or restrictions to delivering training in particular settings. This might include:

  • the need for clearance or DBS checks of trainers or external practitioners when working with police or in certain settings (schools, custody suites, prisons etc.)

  • being clear on the information and time required to secure these when designing, commissioning or creating your delivery plan, communicate this to delivery partners and consider optimism bias in your planning

  • considering the mitigations to a delay in delivery if personnel are not able to secure clearances in time or are unable to complete all the delivery, for example if you need to replace key personnel part-way through delivery

  • some sectors/locations having particular restrictions that need to be taken into account when planning training or other forms of support. This could include shift patterns, remote workers, very limited organisational capacity or specific days/times allocated for training (for example training in schools or with teachers is often confirmed early in the year for the whole school year as there are very limited days and times available)

Having a thorough co-design process which includes representatives from the sectors and professions you intend to train, or including their representation in any programme governance structures should enable you to spot these kinds of issues in advance and mitigate them as part of your programme commissioning process or programme design.

Train the trainer

Train the trainer (TtT) can be an effective way to quickly scale the delivery and impact of a training programme. However, it comes with significant risks you should consider before deciding on this as a delivery model. In some organisations there are also existing training teams who may be able to adapt to deliver your TI programme, however this approach is also subject to similar risks as set out below:

See the qualifications, skills and experience section above: Are you sure the trained trainers will have the appropriate mix/levels of these to deliver the quality you require? How will you maintain those criteria over the longer-term?

Do the trained trainers have the skills to appropriately respond to instances of triggering or re-traumatisation within the training? Do they have sufficient knowledge of appropriate support available in such instances?

Monitoring & Evaluation: How will you measure the quality, effectiveness and impact of the training to end beneficiaries? How will you capture any learning and recommendations to continue to iterate/improve the design and delivery. Also see Evaluation section below.

If you need to make changes to the content or way the training is delivered in the future how will you cascade this and ensure consistency of message, content and delivery?

Have you considered the risks if the training is delivered poorly, or participants receive incorrect or outdated information?

Virtual or in-person training?

VRUs have used varying approaches to training delivery. Whether delivered virtually or in- person, both approaches can be effective and you should weigh the pro’s and con’s of each format before deciding which model suits you best. You may also opt for a hybrid model, for example a basic training delivered virtually and some in-person trainings for different groups/sectors, for example for managers/senior leaders or as part of an advanced or supplementary training offer. We are not currently aware of any evidence that suggests either format is more or less effective than the other.

Considerations for virtual training:

The main disadvantage to virtual training is that there is often a considerable drop- out rate (especially if free). You may need to put additional effort into communications, ask people to re-confirm their place and commitment to attend or think of incentives such as informing people’s employers if they do not attend.

Think carefully about the optimum group size in a virtual environment that will still ensure people are comfortable enough to ask questions and participate.

Think about how you can build trust in a virtual environment to make people comfortable discussing sensitive topics – see Managing trauma in training below.

Consider ways you can keep the training engaging and interactive. How will you cater to different learning styles in the virtual environment?

If you are using virtual workshops or group discussions think about how you will capture the outputs of these and/or support participants in the group sessions.

Let participants know whether you will send out slides and any resources referred to in the training.

Considerations for in-person training:

This may mean you reach fewer people and incur additional costs (for example venue, travel, food and drink). However, there may be significant upsides in terms of building relationships and trust with and between attendees, particularly if the training is across multiple teams and services.

There may be opportunities where partners are able to provide a venue for free or reduced costs, however you should ensure that the venue is appropriate to deliver this kind of training in and accessible for participants.

Consider if you hold all your training in the same venue, could this exclude or dissuade some of your intended participants from attending?

Think about including some time for participants to get to know each other and explore connections between their work and how you can apply this to implementing TIP at a systems level.

Managing trauma in training

A key assumption of TIP is that trauma is widespread and more prevalent than people might initially realise. You should therefore assume that participants in your training will come with their own traumatic experiences, and that this might also act as a barrier to engaging with the training itself. You should have a plan as to how to manage this in the training environment and communicate clearly with participants before, during and potentially after the course to ensure you are delivering in a trauma-informed way.

Ensure your trainers/delivery personnel are sufficiently qualified and experienced to support people or sensitively address concerns if they are raised by participants. See Qualifications, skills and experience above.

Pre-screening – If it’s appropriate you might ask people to flag prior to the training if they think they might find it challenging for any reason. You don’t necessarily need to know the specific reasons, but it could help trainers identify if they might need to check-in with them at any point during the training.

Tips for self-regulating during training – You might wish to cover at the start some practical tips and exercises people can do during the training or breaks if they feel the need to ground themselves. This can be as simple as a breathing exercise, taking a short walk or pressing their thumb and fingers together repeatedly.

Be flexible and allow time for breaks – If you feel a topic has been particularly challenging, you should be prepared to adapt your training schedule to give participants time and space to regulate.

While you might wish to encourage people to keep their cameras on in a virtual environment, you should give them space to turn them off, or permission to leave the room at any point if they need.

Give appropriate warning if you are going to use examples or case studies which reference a particular traumatic event or subject.

Ensure you are able to sign-post people to further support if they need it, this might include knowing the welfare offer, policies or appropriate personnel for the organisations who are receiving the training.

The trainers may also wish to offer support post-session if someone requires it, though they should be clear about their boundaries and the level of assistance they can offer.

Case study: West Midlands – Implementing TIP in custody settings

In Autumn 2021, Barnardo’s staff began the implementation of a trauma awareness programme with West Midlands Police custody staff, commissioned by the West Midlands Violence Reduction Partnership. The programme was delivered in learn, implement and review phases.

The learn phase consisted of focus groups with custody staff; shift observations; interviews with custody focussed researchers and academics; interviews with young people who had experience of custody; and walkthroughs of the physical environment of custody blocks. The team then co-designed training inputs with serving and former custody staff.

The implementation phase involved training, physical changes and embedding learning. This consisted of:

  • co-delivering half day trauma awareness training to all custody staff with a former custody officer (Inspector)

  • the creation of a trauma aware champions group amongst custody staff, and an online resource bank for all staff to access and for trauma aware champions to continue to update and promote the use of

  • Barnardo’s staff supporting West Midlands Police’s efforts to better co-ordinate interventions for young people based in custody run by public and third sector organisations

  • alterations to the physical environment and processes of custody including memory aids to be located at booking in desks with key themes from the training, calming murals painted in cells of the young persons’ wing, easy read rights and entitlements booklets, improved food options and reading materials and the installation of clocks in the light recess to help self-regulation and reduce anxiety

  • the use of distraction packs for young people and ‘tough-book’ tablets with teachable-moment-linked educational content

  • the use of emotional safety plan worksheets

The programme evaluation concluded that training led to an “immediate impact on knowledge of trauma-informed practices”, and qualitative measures “suggest that the TI training programme has a positive influence on police practice and that further efforts to provide TI training to police officers and senior management should be considered.”

The evaluation particularly praised the champions group as helping to embed learning from training over the longer term, indicating the need for more time to be granted for trauma awareness programmes to be implemented. Dip samples from West Midlands Police indicated that the use of distraction packs helped to calm young people in custody preventing self-harm and confrontation towards staff. The evaluation also found that whilst initially sceptical, many staff had embraced the changes once it became clear that trauma aware approaches were of benefit to staff as well as young people in custody.

Trauma-informed practice as part of systems leadership

TIP can enable VRUs to sustainably enhance their systems leadership and embed multi- agency working. TI training (as part of a comprehensive TI strategy) can influence specific changes in practice, both of which can be embedded in wider systems of support. These can enhance the provision of evidence-based interventions,[footnote 2] for instance by improving the quality and suitability of referrals. This might be achieved through creating communities of practice, or standardising practice and procedures (so similar tools, referral pathways, data and language are used to enhance outcomes and avoid the potential for re-traumatisation through engaging with multiple services/systems). This approach is illustrated in the Lancashire and West Yorkshire case studies below.

This approach to multi-agency working and systems leadership was identified by independent evaluators as a core strength and example of good practice for VRUs’ delivery in 2022. Evaluators found that the training and support provided by VRUs supported implementing changes to partners’ longer-term strategies and policies:

“Elements noted as sustainable included trauma-informed training provided to professionals, and supporting changes to partners’ longer-term strategies and policies. An example of the latter included the VRU supporting education partners to update local schools’ exclusions policies for students found in possession of a knife.”[footnote 3]

When thinking about implementing TIP across systems, a few key elements to consider include:

  • identifying champions within organisations, potentially at different levels or across different teams to continue to advocate for the approach and reinforce practice beyond training. Additional training for champions may be necessary, but could be more sustainable than delivering top-up or refresher training to all staff

  • developing a network within and between organisations (could be linked to champions) to take forward additional work, develop recommendations, propose changes to policy and practice as well as continue to develop knowledge and cascade it internally and externally

  • creating a bank or library of resources practitioners can continue to access and where new resources can be stored, updated and easily accessed

  • ensuring there are good, clear and accessible referral routes to available evidence- based support and trauma-specific (for example therapeutic) interventions

  • paying due consideration to the language and vocabulary used in services design and delivery, policies and practice

  • building in mechanisms for co-design with those with lived experience across different services/sectors and who have different experience of trauma and vulnerabilities (both practitioners and beneficiaries)

  • ensuring there are specific roles and structures such as delivery boards, senior responsible owners and named leads who are connected across the system. They may have specific programmes of work to progress implementing TIP both in their own sector and through collaboration with each other

Case study: West Yorkshire – Multi-agency partnership working

NHS West Yorkshire Integrated Care Board (WYICB) / West Yorkshire Health & Care Partnership (WYH&CP) and West Yorkshire Violence Reduction Unit (WYVRU) share a common commitment with all partners across the system to prevent harm and improve the wellbeing of our population. A key strength of the partnership is the convening of different sectors and organisations that wouldn’t traditionally work together to share and build on the wealth of expertise and knowledge that exists across our system. By developing a strong foundation for the partnership, building relationships, and working together as a team, further opportunities and collaborations have become available that might not otherwise have been within reach, including the West Yorkshire Adversity, Trauma and Resilience (ATR) Programme.

The Vision: ‘Work together with people with lived experience and colleagues across all sectors and organisations to ensure West Yorkshire is a trauma-informed and responsive system by 2030’.

The West Yorkshire Adversity, Trauma and Resilience (ATR) Programme

The West Yorkshire ATR Programme was established in June 2020 during a significant time of adversity. Our ethos was then, and continues to be, about connections.

Connecting organisations, communities, and individuals to understand adversity, trauma, and the impact across the life course to both physical and mental health, to understand our services better, prevent re-traumatisation and offer better care for all that is equitable and accessible.

The approach is for all organisations, sectors, and system leaders to work together as trauma and adversity cannot be prevented and responded to by one sector. The programme is co-produced by over 500 professionals and people across West Yorkshire and all 5 places, with each place leading on their local ATR programmes and delivery.

The West Yorkshire ATR provides support across the system to improve health and wellbeing outcomes for the population and workforce through the following ambitions:

  • Prevent adversity and trauma across the life course.

  • Prevent and intervene early to reduce adversity and trauma as a result of poverty and inequalities.

  • Respond to trauma and adversity that already exists, mitigating harm where possible.

  • Facilitate an integrated trauma-informed and responsive system that enables all children and young people, including those with complex needs to thrive.

  • Build and strengthen resilience assets and protective factors for individuals and communities.

  • Reduce risks and improve outcomes for those who experience adversity and trauma.

  • Ensure CYP can develop meaningful relationships with experienced professionals, who will be champions on their behalf, placing them at the centre of care, coordinating services around the child & family.

  • Provide senior clinical leadership across the system, strategic oversight, embedded reflective practice, specialist input and psychosocial interventions.

  • Ensure an understanding of adversity and traumatic events and the impact they have on an individual, their life chances and opportunities.

  • Develop our response to adversity, trauma, and complex needs in this window of opportunity to build back better and fairer and minimise harm caused by COVID -19 and associated measures.

Examples from West Yorkshire of how this change is being implemented include (but are not limited to):

Case study: Lancashire – A trauma-informed approach to data sharing

The Family Hubs Information Sharing Service (FHISS) is Lancashire’s solution to the large amount of information and data being captured and held on children, young people, and families, being largely shared manually across services. This solution is based on learning and best practice from areas such as Thames Valley, Bristol, and Liverpool, with the aim of creating a ‘golden record’ (single source of data truth) to ensure trauma-informed approaches are at the forefront of practice and response.

Lancashire has recognised issues and challenges with the current processes that impact directly on communities, such as practitioners spending excessive time inputting and processing information and therefore having less time to focus on delivering quality outcomes for families; delays in information sharing due to differing and incompatible systems; families having to constantly re-tell their stories to practitioners in different services; limited capability and resource within services meaning delays and inaccuracies in information sharing; and ultimately, there being no holistic view being formed of the needs of a family, the services they are receiving and which practitioners they are working with and therefore as a result, a lack of system join-up and partnership working.

By recognising this need for a trauma-informed response to data sharing, Lancashire are working across partners, services and organisations, such as Local Authority, NHS, Police, Public Health, and Schools, to create this solution which will allow data to be securely shared in a standardised, and automated way with appropriate services and practitioners. This will minimise the excessive time spent on data processing, therefore ensuring practitioners can provide the right service, at the right time to communities. Additionally, this solution has obtained leadership buy-in and funding from both the police and the Integrated Care Board (ICB) to create a ‘tunnel’ like process which will automate the relevant data from these organisations into the FHISS, creating a holistic view of Lancashire communities. This process is intended to be embedded over the next several years as part of delivering the partnership vision that children, young people and families are safe, healthy and achieve their full potential.

Theory of change and evaluation

Theory of change and TIP outcomes

When developing your Theory of Change (ToC), you might wish to consider a range of outcomes across different groups or sectors (for instance for end beneficiaries, professionals/practitioners and for organisations, services and systems). There may also be sector specific outcomes, for example educational attendance or attainment depending on the sector or setting you are implementing your project in (not covered here).

You should make use of the best available evidence to support your choice of approach, the activities that will deliver it and the outputs and outcomes you expect to achieve. Where you identify gaps in evidence or it is weakest, this can be used to generate your evaluation questions and help prioritise which activities/outcomes you might focus on evaluating.

In addition, it can also be helpful to identify the barriers, enablers and assumptions that sit behind your ToC. By bringing stakeholders together to identify these you are most likely to develop a comprehensive picture, mitigate potential risks and issues and generate buy-in for implementation.

You should consider whether the outcomes you identify are likely to come in the short, medium or long-term as this will help you prioritise and evaluate your programme. For the purposes of evaluation, we recommend focussing on the short- and medium-term outcomes you expect to achieve unless you are involved in a long-term impact evaluation. Even if you are looking at evaluating short- and medium- term outcomes, it may still be beneficial to measure these over a longer time-frame (for example 1-2 years). For instance, you may wish to measure whether improvements in practitioners’ knowledge and confidence are sustained.

You should also ensure that your project activities are clearly related to the outcomes you expect to achieve and be clear about how those activities will lead to those outcomes, for example how the knowledge you expect practitioners to acquire through training might lead to identifiable or specific changes in practice, and then how these in turn will lead to the changes you hope to make for your end beneficiaries.

An example of how to articulate these connections could be:

  • increased knowledge leads practitioners to challenge their assumptions and increase their confidence and communication skills in using trauma-informed language and tools in their practice;

  • this enables practitioners to spot trauma-induced behavioural responses and react in a trauma-informed manner;

  • this change to ways of working is supported by organisational changes to policies and procedures which help to embed and reinforce practitioners’ new knowledge, ensuring it becomes standardised in practice;

  • this allows practitioners to build stronger relationships with beneficiaries, enables them to ask the right questions and make better assessments in their decision- making;

  • decisions should therefore be better suited to beneficiaries’ needs, leading to an increase in accessing the right services at the right time.

Table 2 below gives several examples of the outcomes that VRUs have aimed to achieve through their TIP programmes, which we have organised into suggested short- medium- and long-term (not comprehensive or definitive). However, there are currently varying levels of evidence to support these outcomes and some are more complex than others (see Limitations of TIP section above). The outcomes the EIF viewed as being most plausible, based on the existing evidence base include: increasing knowledge and understanding of trauma, shifting perceptions, and contributing to changing practice and making improvements to multi agency working (when other TIP components are implemented alongside TI training).

Table 2: Examples of TIP Outcomes

Practitioners

Short-term

Increased practitioner knowledge of ACEs, trauma and its causes, trauma-informed practice, and use of this knowledge in professional practice

Confidence in applying knowledge of trauma

Medium-term

Improved staff recognition and response to trauma

Reduction in vicarious trauma

Improved wellbeing and resilience

Long-term

Improved staff retention

Reduced burn-out

Organisations / Systems

Short-term

Improvements or changes to frontline practice, policies or processes

Improved structures of support for staff well-being

Medium-term

Better multi-agency collaboration, for example multi-agency case formulation / intervention planning

Improved referrals between partners

Changes in systems, for example better data and information sharing processes between agencies

Reduced violence in specific settings

Improved organisational recognition and response to trauma

Long-term

Common TI policies and strategies across agencies

Consistency in use of TI language across services

End Beneficiaries

Short-term

Improved relationships with staff and trust

Improved access to and engagement with support services and specialist therapeutic services

Medium-term

Improved emotional regulation and trauma response

Improved wellbeing

Reduced behavioural difficulties

Reduction in re-traumatisation

Long-term

Improved sector-specific outcomes, for example educational attainment or reduced offending, leading to improved life chances

Evaluation

The evidence-base for TIP is still emerging and VRUs and partners can play an important role in helping to develop it further by generating appropriate high-quality evaluation of their TIP programmes. However, as TIP is often implemented at the level of practitioners, organisations and systems, evaluating its impact is extremely complex.

It is important to remember that system-level outcomes are influenced by a range of factors at a local level (including the quality of support services for beneficiaries and systems that support staff wellbeing). This makes measuring the specific contribution of training / TIP challenging. One option could be to take a place-based approach and look at the contribution of the training and practice within a wider set of activities at a local level, though it may be hard to robustly evidence its specific impact.

There is currently no one set tool for evaluating the impact of TIP. However, the attitudes relating to trauma-informed care (ARTIC) scale has been used by several VRUs to evaluate staff outcomes in relation to training, as well as in the youth justice sector and is a validated scale. The ARTIC tool is a licensed product that is not free to use.

Beyond outcomes for practitioners, VRUs should consider how they might also measure outcomes for end beneficiaries and including these where possible in the evaluation design, while being realistic about what is feasible within time and cost constraints.

Considerations for evaluation:

Build evaluation in from the start of programmes if possible. This gives evaluations the best chance of getting the necessary data, including baseline comparison data, and finding ways to integrate data collection into routine work. It will also help evaluators understand the journey of staff and systems and more easily identify changes and impact of TIP on the systems and practices it is integrated into.

Recognise that TIP has a long outcomes chain because it is usually working at practitioner/organisational level and changes to knowledge/practice take time to affect relationships and then more time to result in better outcomes for beneficiaries. Think carefully about the intensity and duration of the intervention, link it your ToC, and consider the timescale an evaluation has to collect data and what outcomes and data are feasible. It may only be possible to measure your short- or medium-term outcomes, though you may be able to measure these over a longer time frame (for example 1-2 years) to see if improvements or changes are sustained.

You may also need to prioritise which outcomes you are looking to evaluate due to cost constraints. If your evaluation budget is limited it is better to focus on a few key outcomes in-depth and get good data and evidence than to try and include more outcomes by using less robust methods.

Outcomes should be measured at least six months after training has been completed to assess if any knowledge has been retained and led to changes in behaviours. Ideally there should be multiple post-test points to see if knowledge and practice have been retained and maintained over time.

Having matched comparison groups: A matched comparison group allows you to compare the change and difference in knowledge and practice between workforces who have received the TIP intervention and those that haven’t, to better understand the impact of training or practice outcomes. This is a robust way to evidence impact, but can be complex to implement in practice and needs to be built into the design before the programme starts.

Using qualitative methods (for example, focus groups, interviews, case studies): The use of qualitative methods can aid in providing a more in-depth understanding of how and why interventions might impact staff, systems and beneficiaries and who might benefit most from these interventions. You might want to include training providers, senior managers, practitioners and end beneficiaries (if appropriate).

Feedback surveys: Can be a useful format alongside pre- and post-course surveys to examine the engagement and interest in training content from attendees as well as exploring knowledge attainment or how they will implement what they have learned in practice.

Observations: Observations can help delivery providers to understand and monitor a process as it occurs, helping to gain insight into practitioners’ engagement, interactions and behaviours. Observations are also a great way to quality assure your programme and ensure consistency as well as understand any changes or adaptations needed for specific audiences.

Comparability: Where VRUs are able to align their approaches to evaluation, for example by using the same tools to measure impact (particularly validated surveys), they should do so. This would greatly increase the ability to compare different approaches and understand the impact of differences in design and delivery of TIP.

Resources and further information

Guidance and research

ACE Hub Wales, Trauma-Informed Wales (traumaframeworkcymru.com)

ACE Hub Wales, 2022, ‘Trauma-informed’: Identifying Key Language and Terminology through a Review of the Literature

Department for Levelling Up, Housing and Communities (DLUHC), 2023, Trauma Informed Approaches to Supporting People Experiencing Multiple Disadvantage

Early Intervention Foundation (EIF), 2019, 10 Steps for Evaluation Success

Early Intervention Foundation (EIF), 2020, Adverse childhood experiences: What we know, what we don’t know, and what should happen next

Early Intervention Foundation (EIF), 2022, Trauma-informed care: Understanding the use of trauma-informed approaches within children’s social care

Early Intervention Foundation (EIF), 2022, Understanding the potential of trauma-informed training in violence reduction units

Emerald Insight: Trauma-Informed mental healthcare in the UK; what is it and how can we further it’s development

HM Inspectorate of Probation, Adversity and Trauma

L.Hilder, H.Strang, S.Kumar, 2021, Adverse Childhood Experiences (ACE) Among Prolific Young Robbery Offenders in London: Targeting Treatment for Desistance?

Office of Health Improvement and Disparities (OHID), 2022, Working definition of trauma- informed practice for the health and care sector

P.Gray, H.Smithson, D.Jump, 2021, Serious Youth Violence And Its Relationship With Adverse Childhood Experiences

Research in Practice, Tackling Childhood Exploitation Practice Principles: Tackling Childhood Exploitation Practice Principles: Recognise and respond to trauma Scottish Government, 2021, Trauma-informed practice: toolkit

Substance Abuse and Mental Health Services Administration (SAMHSA), 2014, SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach

Trauma-Informed Lancashire: Resources Traumatic Stress Institute: The ARTIC Scale UK Trauma Council: Resources and Research

West Yorkshire Health and Care Partnership: Adversity, Trauma and Resilience Knowledge Exchange event resources

Youth Endowment Fund Toolkit: Trauma-Informed Training and Service Re-Design

Projects and Evaluations

Anna Freud Centre, 2022, Independent Evaluation of the Framework for Integrated Care (SECURE STAIRS)

Bangor University, 2021, Adverse childhood experience (ACE) and trauma-informed approaches in youth justice services in Wales (2021): An evaluation of the implementation of the enhanced case management (ECM) project

Home Office, 2023, Violence reduction units, year ending March 2022 evaluation report Liverpool John Moores University, 2023, Merseyside Police Trauma-Informed Training: Impacts on Trauma-Informed Knowledge and Attitudes

Opinion Research Services, 2023, Enhanced Case Management Evaluation, South West England (2023): Phase one report

Public Health Wales, 2019, The Prisoner ACE Survey (Wales): Understanding the prevalence of adverse childhood experiences (ACEs) in a male offender population in Wales Public Health Wales, 2017, An evaluation of the ACE Informed Approach to Policing Vulnerability Training (AIAPVT) pilot

Youth Endowment Fund (YEF), Co-Funded TI Grant Round, Trauma-informed practice and preventing young people from becoming involved in violence - Youth Endowment Fund

  1. EIF, 2020, https://www.eif.org.uk/blog/we-need-to-do-something-to-stop-aces-but-universal-ace-screening-is-probably-not-the-best-place-to-start (accessed 18 May 2023) ↩

  2. As mentioned above (‘Trauma-informed practice’, p.4) and according to the EIF report, ‘Understanding the potential of trauma-informed training in violence reduction units’ (2022, p.8), TIP should be “integrated into a system of interventions with good evidence of either preventing or reducing youth violence. These might include focused deterrence, mentoring, pre-court diversion or social skills training, alongside wider system change activities”. ↩

  3. ‘Violence reduction units, Year Ending March 2022 Evaluation Report’ (2023, 3.13). ↩

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